Manual of

Total
Mesorectal
Excision

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HEBK001-FM.indd 2 11/02/13 6:40 PM
 Manual of
Total
Mesorectal
Excision

Edited by
Brendan Moran, MCh, FRCSI, FRCS, Consultant Surgeon Basingstoke
and North Hampshire NHS Trust; Honorary Senior Lecturer,
Southampton University, UK

Richard John Heald, CBE, MCHIR, FRCS, Clinical Director, Pelican

Cancer Foundation, Basingstoke, UK; Honorary Professor of Surgery,
Southampton University, UK; President of the Colostomy Association

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 CRC Press
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 Contents

Contributors vii

  1 The evolution of a concept: the total mesorectal excision story 1

R.J. Heald
  2 Anatomy of the rectum, anal canal and pelvic floor 31
Thilo Wedel
  3 Clinical ultrasound 52
Oliver Shihab, Arcot K. Venkatasubramaniam
  4 Magnetic resonance imaging staging of rectal cancer 58
Peter How, Gina Brown
  5 Radiological staging for systemic disease 71
Gina Brown, Chris Hunter
  6 Preoperative radiotherapy and chemoradiotherapy for rectal cancer 87
Rob Glynne-Jones, Mark Harrison
  7 Total mesorectal excision for rectal cancer 103
Brendan Moran
  8 Abdominoperineal excision of the rectum 124
Torbjörn Holm
  9 Laparoscopic surgery 140
Katharine E. Bevan, Tom D. Cecil
10 Robotic total mesorectal excision 154
M. Chadwick, H.S. Tilney, A.M. Gudgeon
11 Local excision and transanal endoscopic microsurgery 171
Wolfgang B. Gaertner, David A. Rothenberger
12 Pathology assessment 191
Philip Quirke, Tim Palmer, Gordon G.A. Hutchins, Nick P. West
13 Assessment and management of recurrence 203
Peter J. Lee, Kirk K.S. Austin, Michael J. Solomon
14 Lateral pelvic side-wall nodal involvement in rectal cancer 222
Hideaki Yano, Brendan Moran
15 Intestinal stoma and the role of defunctioning a low anastomosis after
anterior resection 228
David Mitchell, Kandiah Chandrakumaran, Steven Arnold
16 Quality of life in patients undergoing abdominoperineal excision and anterior
resection for rectal cancer 239
Peter How, Kandiah Chandrakumaran

Index 249

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Steven Arnold
Consultant Surgeon, Department of Surgery,
Basingstoke and North Hampshire Foundation
Trust, Basingstoke, UK
Kirk K.S. Austin
Department of Colorectal Surgery and Surgical
Outcome Research Centre (SOuRCe), Royal Prince
Alfred Hospital, Sydney, Australia
Katharine E. Bevan
Basingstoke and North Hampshire Hospital
Foundation Trust, Basingstoke, UK
Gina Brown
Consultant Radiologist and Honorary Senior
Lecturer, Royal Marsden NHS Foundation Trust,
Sutton, UK
Tom D. Cecil
Consultant Surgeon, Department of Surgery,
Basingstoke and North Hampshire Hospital
Foundation Trust, Basingstoke, UK
Michael Chadwick
Consultant Laparoscopic Colorectal Surgeon,
St Helens & Knowsley Teaching Hospitals,
NHS Trust, Merseyside, UK
Kandiah Chandrakumaran
Associate Specialist, Department of Colorectal/
Pseudomyxoma Surgery, Basingstoke and North
Hampshire Hospital Foundation Trust, Basingstoke, UK
Wolfgang B. Gaertner
Division of Colon and Rectal Surgery, Department of
Surgery, University of Minnesota, Minneapolis, MN, USA
Rob Glynne-Jones
Consultant Clinical Oncologist and Macmillan Lead
Clinician in Gastro-Intestinal Cancer, Mount Vernon
Cancer Centre, Northwood, UK
Mark Gudgeon
Department of Colorectal Surgery,
Frimley Park Hospital, NHS Foundation Trust,
Frimley, UK
HEBK001-FM.indd 7
Contributors
Mark Harrison
Consultant Clinical Oncologist, Mount Vernon
Cancer Centre, Northwood, UK
R.J. (‘Bill’) Heald
Director of Surgery, Pelican Cancer Foundation,
Basingstoke, UK
Torbjörn Holm
Associate Professor of Surgery, Section
of Coloproctology, Department of Surgical
Gastroenterology, Karolinska University Hospital,
Stockholm, Sweden
Peter How
Colorectal Research Registrar Pelican Centre,
Basingstoke & Croydon University Hospital
Chris Hunter
Colorectal Surgeon, Royal Marsden NHS
Foundation Trust and Croydon University Hospital,
Surrey, UK
Gordon G.A. Hutchins
Department of Pathology and Tumour Biology, Leeds
Institute of Molecular Medicine, University of Leeds;
and Leeds Teaching Hospitals Trust, Leeds, UK
Peter J. Lee
Department of Colorectal Surgery and Surgical
Outcome Research Centre (SOuRCe), Royal Prince
Alfred Hospital, Sydney, Australia
David Mitchell
Colorectal Fellow, Department of Surgery,
Basingstoke and North Hampshire Foundation
Trust, Basingstoke, UK
Brendan Moran
Consultant Surgeon, Department of Surgery,
Basingstoke and North Hampshire Foundation
Trust, Basingstoke, UK
Tim Palmer
Department of Pathology and Tumour Biology, Leeds
Institute of Molecular Medicine, University of Leeds;
and Leeds Teaching Hospitals Trust, Leeds, UK
11/02/13 6:40 PM
 Philip Quirke
Department of Pathology and Tumour Biology,
Leeds Institute of Molecular Medicine, University of
Leeds, Leeds, UK
David A. Rothenberger
Division of Colon and Rectal Surgery, Department
of Surgery, University of Minnesota, Minneapolis,
MN, USA
Oliver Shihab
Basingstoke and North Hampshire Trust,
Basingstoke, UK
Michael J. Solomon
Department of Colorectal Surgery and Surgical
Outcome Research Centre (SOuRCe), Royal Prince
Alfred Hospital and Discipline of Surgery, University
of Sydney, Sydney, Australia
H.S. Tilney
Consultant Colorectal Surgeon, Frimley Park
Hospital, NHS Foundation Trust, Surrey, UK
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Arcot K. Venkatasubramaniam
Consultant Colorectal Surgery, Basingstoke and
North Hampshire Foundation Trust,
Basingstoke, UK
Thilo Wedel
Head of the Center of Clinical Anatomy, Institute of
Anatomy, Christian Albrechts University of Kiel, Kiel,
Germany
Nick P. West
Department of Pathology and Tumour Biology,
Leeds Institute of Molecular Medicine, University of
Leeds; and Leeds Teaching Hospitals Trust,
Leeds, UK
Hideaki Yano
Consultant Surgeon, Department of Surgery,
National Centre for Global Health and Medicine,
Tokyo, Japan
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The evolution of a concept: the total
mesorectal excision story (for surgeon
or patient alike)
R.J. (‘Bill’) Heald
Introduction
One German professor, a great friend, suggested that
I should write the story of how it became possible to
conquer the whole world with an idea–a concept–
a guiding principal of surgical technique–to tell in
fact how the words Total Mesorectal Excision (TME)
moved from humble beginnings in Basingstoke to
become a part of any discussion about rectal cancer
anywhere in the world (Figure 1.1).
A personal reflection on the key components of
the TME story over a period of 30 years may elu-
cidate some of the issues and encourage others to
follow an idea born out of clinical observation at
the surgical coalface.
In the late 1970s, when I was a young consult-
ant, almost half of all patients with rectal cancer
died from local recurrence – that is, regrowth of the
cancer within the pelvis. The pelvis became gradu-
ally permeated by malignant tumour, which infil-
trated all pelvic contents, particularly pelvic side-wall
nerves and the sacral nerve roots to the legs, eventu-
ally causing intractable pain, paralysis and inconti-
nence – all adding up to one of the most miserable
forms of death ever dreamed up, and all terribly slow.
Unsurprisingly, almost 100 years before this, H.W.
Maunsell stated in the Lancet in 1892:
HEBK001-C01_p01-30.indd 1
1
All carcinomas of the lower sigmoid and upper
rectum are tabooed by all practical surgeons on
account of their anatomical inaccessibility. All are
abandoned without hope to linger on for a few
months until death relieves them of their
loathsome condition.
On this background, all who tackled rectal cancer
surgery had to contend with many failures and ter-
rible outcomes in the patients who developed local
recurrence.
The TME story starts with its roots in embryol-
ogy and its basis in anatomy.
Embryology
Embryology was always a challenge for me as a stu-
dent to grasp the mysteries of one cell turning itself
into a fetus with a near certainty of becoming a human
being. One special mystery was that ‘tube’ from mouth
to anus that was somehow programmed to sprout the
potential liver in one direction and the pancreas in
another, and then, before the fetus is 1 cm long, to take
a journey out of the primitive abdominal cavity and
subsequently back into it, thus setting the components
of the gastrointestinal tract in their appointed order
11/02/13 3:43 PM
 2  The evolution of a concept: the TME story
Figure 1.1. Worldwide TME. Some of the TME venues, comprising more than 450 invited operations in more than
40 countries. At the time of going to press the Queen’s Birthday Honours List presented the CBE to Professor Richard
Heald for services to UK surgery internationally.
and placement and establishing the marvel of the
human alimentary system in situ. My personal story is
of gradual realization that this midline gut tube can be
redefined with its intrinsic ­lymphovascular ­surround
as a midline envelope recognizable for surgeons by
the spider’s web of areolar tissue around it. The dis-
tal part of the envelope is around the rectum and
becomes the mesorectum, and the cobweb around it
where the surgeon dissects is the ‘holy plane’. Each part
of the envelope has an artery coming from the front
of the aorta, rather than the side like everything else.
The key hypothesis was that each part of the envelope,
if very carefully removed en bloc, might have a very
good chance of enveloping the whole primary field of
spread of a cancer and thus curing all but the most
advanced cases (Figure 1.2).
The TME story is inextricably linked with embryol-
ogy, and it is probable that similar concepts might be
applicable to many other cancers, since the constraints
to cancer growth, such as areolar planes that block
angiogenesis, are relevant to malignant infiltration of
many kinds and in many places ­(Figure 1.3).
HEBK001-C01_p01-30.indd 2
The growing surgeon: ‘on the
shoulders of giants’
These seeds of wonder at embryology lay dormant in
me as surgery became practice. Small flashes of wis-
dom from along the path of surgical training blinked
as possible explanations for good or bad outcomes:
‘The best surgeon is the one with a capacity for tak-
ing infinite pains’ is one such pearl that continues to
flash up with great regularity. Pains to do what exactly?
Advocating TME eventually became a battle to justify
turning a 1 h operation into an increasingly fastidious
and precise operation taking 3 h or more. Initially the
only obvious justification for such a change was the
hope of fewer permanent colostomies. The potential
for improved outcome, survival and cure would not
become apparent for 5 years or more and was never
dreamed of at the beginning.
It is perhaps a measure of the fundamental ethics
of the early British National Health Service (NHS)
of the 1970s and 1980s that no financial or manage-
ment pressure was ever exerted on me to desist from
11/02/13 3:43 PM

Figure 1.2a. The mesorectum surrounded by the holy
plane.
Figure 1.2b. A perfect TME (PO Nystrom).
HEBK001-C01_p01-30.indd 3
Basingstoke, Hampshire  3
Figure 1.3. Pursuable cobweb areolar plane.
such an expensive experiment. Such benign accept-
ance of the time-consuming emerging concept did
not, however, imply that I was not berated and con-
demned by the surgical establishment for the temer-
ity to challenge their supremacy – as outlined later.
One early public condemnation, from Prof Mike
Perry, still rings in my ears today: ‘you are taking on
a grave responsibility by deviating from the radical-
ity of the established orthodoxy of abdominoperi-
neal excision’.
Basingstoke, Hampshire
With an abiding interest in visceral surgery, the early
1970s finds me a consultant surgeon in the little-known
town of Basingstoke in the pleasant countrified county
of Hampshire, about an hour south of London, with
a catchment population of approximately 250 000. I
was the second full-time consultant general surgeon in
the large new hospital under construction. My senior
colleague was the remarkable Mr Frank Tovey, whose
voluntary service in India and China, combined with
his passion for research and teaching, were all truly ser-
endipitous for me. I still remember his standing at my
side in the operating room as I tediously tried to achieve
an early TME. I was embarrassed at my ineptitude, but
he said ‘I think you might have something there, Bill. It
is very different from what everyone else is doing and is
definitely worth persevering with. I will give up doing
rectums and let you have them all.’ This was a key start-
ing point, as becoming the only rectal cancer surgeon in
a District Hospital was then a unique privilege. Speciali-
zation was commencing naturally by mutual consent.
11/02/13 3:43 PM
 4  The evolution of a concept: the TME story
Dividing the mesorectum
1975 (not called that then ....)
No such word in GRAY’s
“ANATOMY”
Anterior resection, as I had been taught, involved
manual extraction of the rectum with much rough tear-
ing of the surrounding fat, sometimes ­uncontrollable
blood loss, and desperate anxiety about leakage from
the anastomosis and later of local recurrence. The latter
was assumed to be largely in the hands of the almighty
and pretty much inevitable. It was frequently stated by
the great and the good that ‘surgery had gone as far as
it could go’. More than 75 per cent of rectal cancers,
and every cancer that could be felt digitally, was offered
only abdominoperineal excision (APE) with perma-
nent colostomy, which was considered much the most
‘radical’ operation and much the safest oncologically.
Anterior resection was believed to add substantially to
the risk of local recurrence.
Cancer recurrence at the suture line dominated
our ideas of follow-up after anterior resection, and
this dictated a digital examination and sigmoidos-
copy. Ultrasound, computed tomography (CT) and
magnetic resonance imaging (MRI) did not exist.
The mesorectum in rectal
cancer: the clue to local
recurrence?
Against this background, clinical experiences and
histological findings with five particular patients sug-
gested that mesorectal residues might be the source of
those very common pelvic recurrences.1 This ‘tale of
five patients’ has, I am told, become the most cited ref-
erence in the whole surgical literature on bowel cancer.
The most memorable, and perhaps most signifi-
cant, of the five thought provoking patients in this
first paper was a publisher called Anthea. Like most
HEBK001-C01_p01-30.indd 4
Figure 1.4. The node contains cancer!
of the TME story, the seminal moment occurred in
the operating room. We were dealing with the all too
common random bleeding in the fat behind the rec-
tum when we noticed a small lymph node less than
1 cm in size. It looked harmless enough, but I lifted it
out and asked the scrub nurse to send it for patho-
logical analysis. A week later the node was reported
as containing a focus of cancer (Figure 1.4). It thus
became apparent that I had cut or torn through the
field of spread of Anthea’s cancer. What to do? A
week later we performed an APE to be properly ‘radi-
cal’, but no further cancer was found in the specimen.
Five years later Anthea died of rectal cancer bony
metastases with a quadriplegia – a memorable and
terrible end to a historic individual in the story of
rectal cancer. It still seems to me that cutting through
cancer, or its field of spread, almost always leads to a
cancer death, unless possibly on occasion when the
tissues have been recently irradiated.
The concept of total excision of the mesorectum
was developing. The idea seemed strengthened by
the referral of a suture line recurrence later that year
when the emptying of the pelvis for an ultra-low
anastomosis revealed a large mesorectal remnant
with a cancer focus growing from it into the suture
line (Figure 1.5).
The other three cases pointed in the same direc-
tion. The paper was published in the British Journal
of Surgery entitled ‘The mesorectum in rectal cancer:
the clue to local recurrence?’1 This key publication
in the rectal cancer literature was simply an idea
based on clinical observation. One of my much
loved former chiefs, Mr Peter Philip, wrote me only
one letter; it said ‘That was the most sensible paper I
have read for a long time.’
11/02/13 3:43 PM

1977
Re-Operation for Suture Line Recurrence 1977
Figure 1.5. Suture line recurrence.
The ‘Russian gun’
The ‘Russian gun’ saga preceded TME and landed
me in trouble before the 1970s were out, and it
certainly contributed to my preoccupation with
TME. The legendary figure of John Goligher,
then Professor of Surgery in Leeds, showed me
the circular stapling gun from Russia, which he
had bought from a bazaar in Turkey for a few
stray coins. ‘Take an interest in this, young man:
it may well have a place in low anterior resection.’
So I bought one on my travels, and, to my eternal
shame, it sat unused in a cupboard for a year until
my encounter with Anne, a young woman with
a large ulcerated carcinoma 5 cm from the anal
verge. For a young woman, recently divorced and
in her early twenties, the thought of a permanent
stoma was unbearable.
At this time, the TME story in my own mind was
at the evolution point where the challenge of meet-
ing this patient’s hopes was just what was needed
to push the TME idea to its logical conclusion. Per-
haps even such a low cancer, at 5 cm, could be safely
removed with all its relevant field of local spread
without sacrificing the pelvic floor and the sphinc-
ter muscles. The mesorectum as a surgical craft
entity was being born – a dream of relevant radical-
ity without unnecessary mutilation.2
For Anne, I deemed it possible to achieve sphincter
preservation, which, though extremely unorthodox,
might just be achievable with that Russian gun. Tor-
tured by the risk of local recurrence, I attempted my
first TME in 1978. For me, the anastomosis with the
HEBK001-C01_p01-30.indd 5
MESORECTUM – THE WORD  5
Russian gun at about 3 cm was the lowest I had ever
attempted, and the circumferential clearance was a
long slow attempt to circumnavigate the cancer by
dissecting in clean surgical planes. Anne thrived for
3 years and then sadly developed liver secondaries,
for which I performed a hemi-hepatectomy. At this
time she had found a new partner. Three years later
she was watching television when she fell uncon-
scious from a cerebral secondary and did not wake
up – merciful but very, very sad. She never had pelvic
recurrence, so the seeds of hope for lower anterior
resections were sewn, and my first TME seemed to
me at least to have been justified with local disease
control.
Mesorectum – the word
I had heard the word ‘mesorectum’, although it was
not in Gray’s Anatomy or anywhere else that I ever
found. My mentor and trainer at Guy’s, Mr Rex
Lawrie, used the word ‘mesorectum’ to describe
the fat behind the rectum that we divided during
conventional anterior resection. This fat often bled
in a tiresome way and so was the object of irritated
abuse on occasions. We have since seen a report of
the word ‘mesorectum’ in an ancient radiotherapy
account of the use of radiotherapy in rectal cancer
in 1914, but, for practical purposes, the word was
undiscoverable at the time. It is attributed in my
mind to one of my personal giants, Rex Lawrie, on
whose shoulders much of my surgical thinking had
certainly been based.
11/02/13 3:43 PM
 6  The evolution of a concept: the TME story
Words Matter
In his book Talking Sense,2 Richard Asher points out
that ‘physicians indulge in conjectural names’ and
cause a great deal of confusion as a result. He quotes
from Socrates: ‘He who first gave names and gave
them according to his conception of the things they
signified, if his conception was erroneous, shall we
not be deceived by him?’
I believe that both Socrates and Richard Asher would
be happy with the phrase ‘total mesorectal excision’ as
it describes exactly what the surgeon should try to do.
It is not easy to do well, but, very fortunately, the sur-
geon who believes in the TME concept and attempts to
do TME is hugely rewarded by improved results.
One enduring problem is that the word ‘mesorec-
tum’ was, and remains, anathema to many anatomists.
Even the current edition of Gray’s Anatomy describes
the mesorectum as the mesentery of the sigmoid
colon. Anatomists describe a ‘meso’ (e.g. mesocolon)
as simply two layers of peritoneum with blood vessels
and lymphatics between them and therefore question
the use of the term ‘mesorectum’ (Figure 1.5).
For me, however, and fortunately for the future
of the concept of TME, this was the point where
oncology and embryology met, and the choice of
the word became descriptively critical and entirely
acceptable to surgeons who were trying to define
the primary field of spread of a rectal cancer. Thus,
the mid-rectum is entirely encompassed circumfer-
entially by its own fat, lymphatics and vascular sup-
ply, all enveloped in a fascial covering, with a recog-
nizable practical surgical plane outside it.
Anatomist Professor Morgado proposed that only
a two-layered mesothelial structure surrounding and
HEBK001-C01_p01-30.indd 6
Figure 1.6. Anatomist’s
mesentery.
suspending a segment of gut may count as a mesen-
tery and that the term ‘mesentery’ is not applicable
to the rectum, since the normal rectum is devoid of
an encircling, suspensory mesothelial sleeve (Figure
1.6).3 I replied:
To the oncological surgeon the term
‘mesentery’ implies an integral visceral,
lymphovascular and fatty entity that nourishes
the organ concerned, and is developed
embryologically in concert with it. In the case
of the mid-rectum, this fatty lymphovascular
structure surrounds the rectum completely, and
no other word but ‘mesorectum’ seems readily
available to describe it. Appreciation of the
surgical anatomy of this entity, and exercising
particular care when dissecting around it,
are important components of good surgical
technique in relation to rectal cancer. Graham
Hill’s term ‘extrafascial excision of rectum’ may
be more acceptable to morphologists – but
is unlikely to displace the term TME from the
surgical nomenclature …’
and ‘his’ fascia is indeed that which surrounds ‘our’
mesorectum.
The initial impact
Early experiences of applying the circular stapling
gun resulted in lower and lower anterior ­resections.4
This stimulated interest in the guns by other sur-
geons, which led to my first travelling phase, large-
ly limited to England. As a young surgeon, I was
11/02/13 3:43 PM
 Data collection and analysis and the pivotal role of Rosemary Sexton  7
Figure 1.7. My first travelling
phase.
instructed to turn up with ‘the gun’ after the cancer
had been removed by the host.
The outcome of such a visit to St Mark’s Hos-
pital in London to demonstrate the ‘new toy’
is nicely illustrated by my friend Mick Elliot
(Figures 1.7–1.9). The Russian gun required that
the staples be individually loaded in addition to
the washer on to which the circular knife cut after
firing of the staples. Undoubtedly the fastidious
Professor Goligher measured each washer’s size
and thickness, but I was content for others to do
this, and I assumed the washers were uniform.
What happened at St Mark’s was that the so-called
‘doughnuts’ were not cut through, although the
staples had fired. The washer was too thin and
the gun could not be removed. Perhaps the Bas-
ingstoke Gazette (Figure 1.10) was right! We all
rejoiced when the US company Autosuture started
to manufacture disposable, more reliable stapling
instruments.
Figure 1.8. Staples fired, doughnut
not released.
HEBK001-C01_p01-30.indd 7
Data collection and analysis
and the pivotal role of
Rosemary Sexton
Evidence was appearing of wide variations in the local
recurrence and survival rates between surgeons, and
Hermanek suggested that TME might be at the heart of
this. The maverick practices of a surgeon in Basingstoke
were unlikely ever to change the practice of surgery in a
fundamental way. Only the most unchallengeable data
with every possible discrepancy covered were likely to
be of any value if what we were discovering was to turn
out to be of any importance. Data collection and man-
agement were initiated by Rosemary Sexton, formerly
my secretary, whose ­husband David worked for Xerox
and who gave us an enormous computer for this pur-
pose. We were ably backed by my cousin Pam who
helped us to create our own dedicated software to cor-
relate preoperative and operative detail with outcomes
in a unique way. Thus, my initial data collections were
11/02/13 3:43 PM
 8  The evolution of a concept: the TME story
comprehensive and consecutive so that there were truly
no exclusions. The quality of the data was enormously
enhanced by the fact that Rosemary made it her busi-
ness to get to know every patient. Of course we made
some mistakes, and the databases required continuing
alterations; for example, initially we failed to record
the quadrant of the rectum where the cancer was situ-
ated. Rosemary attended the outpatient clinics and was
truly the forerunner of what is often now called the ‘key
worker’ in the UK or ‘case manager’ in Europe as part
of the modern multidisciplinary team management of
cancer. She provided a communication lifeline in the
sometimes complex and terrifying journey that follows
a diagnosis of rectal cancer.
The embryonic
multidisciplinary team
and Roger Ryall
The unsung hero of the TME story is Dr Roger
Ryall, a clinical oncologist with an intellect ahead
Figure 1.10. From the Basingstoke Gazette, 1979.
HEBK001-C01_p01-30.indd 8
Figure 1.9. Goodbye, Bill!
of his time, with whom I did a joint clinic. Dr
Ryall’s view of the role of radiotherapy in rectal
cancer was indeed ahead of his contemporaries.
Throughout the USA, and in much of the UK,
radiotherapy was being given to many patients
postoperatively, which he considered to be infe-
rior to radical radiation given before surgery. We
selected for the latter only patients considered to
be locally inoperable as judged by palpable fixity
to adjacent pelvic organs.
The other members of our embryo multidis-
ciplinary team were Rosemary Sexton and stoma
therapist Sister Anne Leppington-Clarke, who pio-
neered irrigation in southern England as a meth-
od of managing a permanent end ­colostomy. She
also worked out ­beautifully how to cope with the
tiresome temporary right transverse colostomy
that we generally performed to protect a low anas-
tomosis for the first 6 weeks. Transverse colostomy
remains my preference to reduce the formation of
small bowel adhesion and abolish the high output
sometimes associated with loop ileostomy, which
enjoys greater popularity at this time.
Early publications
One key early publication emanated from my presi-
dential address to the section of surgery of the ­Royal
Society of Medicine. Two years earlier Mr Geoff
Oates’ presidential address had included the words
‘I don’t know why you don’t believe Bill Heald – he
is a very truthful chap’ – life-saving for me sitting
in the audience at the time. In my own address I
advanced my preoccupation with the embryology
11/02/13 3:43 PM

and ­anatomy to explain the astonishing local recur-
rence figures that were beginning to earn me so
much derision. Unexpectedly good outcomes led
me to choose as my title ‘The holy plane of rectal
surgery’5 and to suggest that embryologically deter-
mined planes might be a sounder basis for optimal
oncological specimens and optimal outcomes than
random sacrifice of the anus. I suggested that there
were widespread misunderstandings about the word
‘radical’. Abdominoperineal excision was much more
radical and therefore much more ‘curative’ than an
anterior resection, but this was in complete contrast
to the surprising data that we were accumulating.
Total mesorectal excision, I suggested, was ‘relevant
precise radicality replacing unnecessary mutilation’.
Publication by a Surgeon and
Radiotherapist About Patients Not
Given Radiotherapy
Our little multidisciplinary team published the
115 cases in the Lancet with just Heald and Ryall
as the authors with the rather straightforward title
‘Recurrence and survival after total mesorectal exci-
sion for rectal cancer’.6
This paper, with outcomes at 2–6 years, was based
on only 115 curative cases (i.e. patients without
metastases). I recall quite primitive attempts to work
out confidence intervals myself, eventually aided by
Figure 1.11. Using the smaller camera.
HEBK001-C01_p01-30.indd 9
Early publications  9
one of the medical students who understood log
ranking and Kaplan–Meier curves. The local recur-
rence of 3.7 per cent was finally calculated based
on these 115 patients. It is intriguing that, when the
numbers had quadrupled, the original Kaplan–Mei-
er prediction was within 0.2 per cent of this initial
calculation, and indeed with gradual narrowing of
the confidence intervals over the years very little has
changed from those original predictions. When a
local recurrence rate of 3.7 per cent in ‘curative’ 115
cases compared so favourably3 with the then accept-
ed figures of 20–40 per cent in various publications,
it is perhaps unsurprising that the original data were
greeted with some scepticism.
A pointer to the future comes from the following
quote in the discussion section of this Lancet paper:
‘On this evidence it is often safe to limit mural
clearance and thus preserve the sphincters provided
the mesorectum is excised intact with the cancer.’6
More than 100 ‘Away Cases’
in Sweden and Norway
By the late 1980s the literature suggested that a Bas-
ingstoke surgeon could achieve local recurrence rate
of less than 5 per cent with anterior resection. Many
felt that either he was lying or he had redefined a
‘curative’ resection in some way to ­optimize ­outcomes
reported. The Scandinavians, particularly in ­Norway
11/02/13 3:43 PM
 10  The evolution of a concept: the TME story
and Sweden, had identified the issues of local recur-
rence in rectal cancer and, after evaluation, had decid-
ed that the addition of radiotherapy could result in
slight improvements but at much risk to the patients
and cost to the health-care system. Professor Soreide
of Oslo invited me as a visiting surgeon to his video-
based ‘super radical cancer surgery’ annual workshops
at the Rikshospital. Here in 1 week, assisted by a suc-
cession of Norwegian surgeons, I performed ten tel-
evised TME procedures while trying hard to dodge
around an enormous broadcast-quality camera. This
news-gathering television camera had been given to
me by Sony Broadcast, serendipitously a Basingstoke-
based company (Figure 1.11).
The Swedish approach differed from Norway’s in
that three surgeons from the central Ostergotland
district asked if they might come to Basingstoke
for a week. After three cases, and intensive study of
video clips from my Sony recording kit, Erik Nillsen
and his colleagues returned to Motala and Norrko-
ping, clearly convinced of the potential of this tedi-
ous ‘TME surgery’. They grasped that only one sur-
geon in each Swedish district could possibly hope to
hone the necessary skills and understanding of the
complexities of the deep pelvic anatomy.
The Swedish TME ‘wave’ (Figure 1.12) was carried
forward by Professor Rune Sjodahl, who organized
a series of workshops in Linkoping. This was fol-
lowed by the first of several honorary professorships,
many lasting friendships and ultimately over 80 visits
across Sweden.
Subsequently, Stockholm became especially impor-
tant, with special friendships established through
HEBK001-C01_p01-30.indd 10
Figure 1.12. Professor Pahlman's depiction
of the effects of TME workshops across
Sweden.
Professor Bjorn Cedemark and the then young
Torbjörn Holm. They and their colleagues coordinat-
ed what we often refer to as ‘Stockholm 3’, a succession
to the famous Stockholm 1 and 2 radiotherapy trials.
Publication of the impact of a series of workshops in
the mid-1990s at the Karolinska Hospital, Stockholm
was the first report to demonstrate that workshop
training in surgical technique can improve cancer
outcomes in a whole population. Ongoing education-
al activities that were thus started have continued to
make a real difference throughout Sweden.
Looking back, it is clear that any world conquest by
the TME story occurred very gradually as surgeons
grasped the unexpected improvements in outcome
that could be achieved by the expenditure of time and
painstaking effort in pursuit of the TME principles.
The first TME after our first workshop in Perth,
Western Australia makes it very clear that a ‘better’
specimen with intact margins will be much less lia-
ble to spill cells or leave cancer-containing residues. I
labelled the goal as ‘specimen-oriented surgery’, where-
by the surgeon’s mind is forever prioritizing the quality
of the specimen as he or she dissects around it. Naked-
eye inspection and a recorded evaluation of the shape,
contours and perfection of the specimen thus became
the key tool in the audit of the quality of the surgery.
Histopathology workshops:
Phil Quirke
As the Scandinavian workshops spread to other
countries, histopathological evaluation of the
11/02/13 3:43 PM

margins of excised TME specimens became part
of the TME ­crusade in a multidisciplinary fashion.
What had been the ‘Travelling Bill Show’ became,
with Phil Quirke from Leeds, the ‘Travelling Bill
and Phil Show’, and the workshops increasingly
embraced not only video relay of the live surgery
but also workshops for pathologists with detailed
audit of the margins and the quality of the speci-
mens. Naked-eye examination and evaluation
of the perfection of the specimen are potentially
humiliating for many surgeons but a key com-
ponent of introducing objectivity and honesty to
improve outcomes.
Television, BBC2 and
Phil Hammond
Without doubt, the most exciting television appear-
ance of the TME story occurred on BBC2, when a
series entitled Trust Me I’m a Doctor was conducted
by a dynamic doctor and investigatory reporter
called Phil Hammond. His colourful coverage of
the ‘Phil and Bill Show’ embraced the experiences
of one young and engaging patient, a natural
television personality who emphasized, straight
into the camera, ‘When it’s your life, you’ve only got
one chance.’ I had often made a similar observation
in relation to rectal cancer that ‘what is omitted at
the first operation is lost forever’.
Phil Hammond interviewed Bjorn Cedermark,
who stated on camera:
[Abdominoperineal resections] and permanent
colostomies were 50 per cent down to 20
per cent, the local recurrence from 22 per cent
down to 5 per cent, and what happened during
1994–1995 was simply the workshops. The
important thing about this is that what we didn’t
really know, we read Bill Heald’s paper for the
first time and Bill knows as well as everyone else
that a lot of people did not believe him. They
said this is not right, we have all been doing this
for years, it cannot be true – well it is true! And
I think we have proven that we can really do
something by changing our surgical habits also
for a population.
Stockholm was perhaps the single most signifi-
cant episode in the establishment of an extraordi-
nary lifelong series of practical video workshops.
HEBK001-C01_p01-30.indd 11
A new form of surgical teaching  11
A new form of surgical
teaching: the live surgery
video workshop and the
birth of nerve recognition
and preservation
The special problem that has beset the TME story
from the beginning is that the operation is difficult
to perform, although the concept of ‘embryological
envelopes’ is easy enough to grasp in theory. Since
good-quality data were accumulating through the
late 1980s and the Scandinavian enthusiasm gath-
ered momentum, the demand for people to see
exactly what was involved grew steadily. Invitations
flooded in from around the world so that the next
25 years have become for me a steady stream of ‘away
cases’, armed with a video camera and backed up by
the ever willing Phil Quirke to bring on the histopa-
thology audit, which was the essence of convincing
surgeons of the need to be ‘specimen-oriented’.
Phil’s commitment has become legendary and
he has criss-crossed the world with the salutary
message that the histopathologist should not only
report on a surgeon’s work but also audit the qual-
ity with ruthless tenacity (Figure 1.13), which is apt
to strike fear into the surgical heart.
Total mesorectal excision video workshops have
introduced surgeons across the world to the true detail
of deep pelvic anatomy. In the late 1980s and 1990s,
the demonstration of the seminal vesicles during a
workshop evoked amazement while video images of
dissection between them and ­Denonvilliers’ fascia
were hailed a first-time experience. Neither cadav-
er dissection nor CT scanning had ever conveyed
an understanding of Denonvilliers’ fascia, a trapezoi-
dal bib or sheet of collagen extending down from the
apex of the peritoneal reflection between the rectal
envelope behind and genitourinary organs in front.
Denonvilliers described in 1837, in his doctoral the-
sis, ‘l’aponévrose pubio-rectale’. Understanding this
medially tapering trapezoidal sheet is truly the key to a
proper TME in a low anterior cancer in male patients
and also the key to preserving potency in all TME
dissections in male patients (Figure 1.14). The anteri-
or mesorectal fat, whose very existence was previously
ridiculed by the top surgical establishment, is very real
but easy to tear, so we have always advocated dissec-
tion anterior to Denonvilliers’ septum (Figure 1.15).
The emergence and widespread use of axial MRI
finally established in everyone’s mind that the anterior
11/02/13 3:43 PM
 12  The evolution of a concept: the TME story
Before
After
mesorectum did indeed exist and that the septum was
often recognizable on a good-quality image.
Video surgery
Many of the initial video workshops were in Basing-
stoke, and it soon became apparent that the quality of
standard videotapes and video cameras was inadequate
to convey the detailed images required. Serendipity
intervened in that the advanced products division of
Sony Broadcast was situated in Basingstoke, only a few
hundred metres from the operating theatres. Here the
first commercially aspiring high-definition television
was being developed, and the education department
in Sony Broadcast became friendly and supportive.
As a result I, who had started life in my teens as a
HEBK001-C01_p01-30.indd 12
Figure 1.13. Histopathology
audit.
cinema operator, found myself with a massive amount
of broadcast-quality video editing material capable of
handling videotape non-linear editing. In the 1980s
one whole room at my house was taken over by the
equipment necessary, and the cost in today’s terms
would have been well over £250 000, provided with-
out charge by Sony. Thus, we were able to record on
professional video format hundreds of operations per-
formed in a variety of different countries, all in broad-
cast quality and capable of conveying to a watching
surgeon the essence of holy plane dissection and the
beginning of the identification of the layer of nerves
that surround the mesorectal envelope.
Throughout the development of the video tech-
nology necessary to identify the autonomic nerves
of the pelvis, the improvement in picture quality
and the recording and transmission of detail have
11/02/13 3:43 PM
 The identification of the nerves of urogenital function  13
Figure 1.14. Denonvilliers’
septum.
been crucial. Further serendipity provided the TME
story with Jason Flowers, a man of unique talent in
the field of computers and computer visualization
of images. It is with his help that we have led the
world in visualizing the fine detail, including the
autonomic nerves and plexuses.
The identification of the
nerves of urogenital
function
‘Man recognizes only what he knows.’ (Goethe)
In the early days some of the most distinguished
surgeons totally rejected the idea that we were
seeing the autonomic nerves responsible for male
Figure 1.15. Dissection anterior to Denonvilliers’ septum.
HEBK001-C01_p01-30.indd 13
erection, ejaculation, and control and normality of
urinary and faecal voiding and continence.
One notable exception was Sir William Slack,
a distinguished London surgeon at the Middle-
sex Hospital. He had, with his histopathologists,
looked carefully at the periphery of rectal cancer
specimens and correlated patient impotence with
the nerves inadvertently removed by the surgeon.
I was not innocent of this myself, and I still show
an earlier teaching video in which I cut through
the superior hypogastric plexus by getting into the
plane outside it at the aortic bifurcation and then
back into the correct plane by cutting through the
nerves on which ejaculation and to some extent the
control of urinary function depend (Figure 1.16).
Figure 1.16. Right erigent pillar.
11/02/13 3:44 PM
 14  The evolution of a concept: the TME story
Most surgeons had been unaware of these struc-
tures, and I was still failing to grasp fully the onion-
like anatomy that must be respected if these nerves
are to be identified, recognized and preserved. The
idea of the onion came from a Japanese visiting sur-
geon, Professor Yoshi Moriya. The onion is a help-
ful anatomical concept, with the mesorectum as the
core, the autonomic nerve layer as the first layer, the
Wolffian ridge ureters and vesicles as the next layer,
and so on. Holy plane dissection is thus the very
careful entry into, and pursuit of, the innermost
proper surgical plane around the core outside the
mesorectal fascia, while recognizing and preserving
the nerve layer outside it.
The detail of the autonomic nerves was the next
frontier and the next major controversy. Nerve
preservation is one of the most difficult challenges
of a good TME. Mesorectal fascial dissection liber-
ates the inferior hypogastric plexus in an area that
was formerly disastrously and improperly named
the ‘lateral ligaments’. Video teaching dissections
made it clear that no actual ligament existed, only
areas of adherence. Simultaneously Japanese anat-
omists Sato and Sato had also noted that middle
rectal arteries coming from the internal iliac vessels
were uncommon, being present in only one in five
patients on one side or the other and bilaterally in
one in ten patients. The routine of clamping and
dividing something called a ‘lateral ligament’ that
also appeared to contain major arteries and veins
(traditionally labelled the middle rectal vessels) had
to be challenged.
My own practical experience was, and is, that sub-
stantial vessels at this level are rare. If the surgeon
dissects carefully between the mesorectal fat and the
inferior hypogastric plexus, only a variable few nerves
entering the mesorectum and some minor vessels are
encountered. These observations suggest that the ‘lat-
eral ligaments’ are no more than areas of adherence
between inferior hypogastric plexus and mesorectum
that tether the specimen inferolaterally. The vessels
that we used to clamp were the lateral intramesorectal
branches of the superior rectals and a part of the lym-
phovascular field that should have been encompassed
and removed. This stage of the dissection is very chal-
lenging and is more achievable with precise monopo-
lar diathermy. Diathermy here, however, does bring
into question the matter of collateral nerve damage,
and so low settings and optimal methodology are
essential areas for ongoing technical research.
HEBK001-C01_p01-30.indd 14
The emergence of magnetic
resonance imaging in a
Swedish workshop
Initial Swedish workshops at the Karolinska Hos-
pital involved two adjacent operating theatres and
transmitted images plus continuous review of MRI
scans with Dr Lennart Blomqvist, their expert
futuristic radiologist. Groups of up to 20 Swedish
surgeons attended, taking it in turns to assist with
the operation. The informal relationship between
small groups of surgeons and personal interaction
has been a unique part of what is undoubtedly a
completely new form of surgical teaching. The
sense of involvement mixed with informality adds
considerably to the learning experience. Similar
arrangements now work extremely well in my regu-
lar Heidelberg workshop series.
Who needs enemies?
Professor Paul Hermanek, a great friend and world-
renowned pathologist, once told me over breakfast
that the TME project would progress much faster if
I didn’t have so many people, many from England
and beyond, belittling it. But to every force there is
a counterforce, and such antagonism often breeds
silent supporters from the quiet majority, and
opponents often do more benefit than harm.
One curious, almost dramatic example of this was
the assault by Professor Isbister, at the time a profes-
sor of surgery in Riyadh. His antagonism appeared to
take the form of an attack on Basingstoke, the inno-
cent town from which the TME idea had emanated.
Various articles appeared under the titles of ‘Basing-
stoke visited’, ‘Basingstoke revisited’ and ‘Basingstoke
visited again’. The essence of the articles was that the
data were wrong and meaningless. Since he had never
visited Basingstoke, my replies constantly reiterated a
warm invitation to him to do so, to see what we were
trying to teach, and to give us his comments on our
work, favourable or unfavourable. He never came.
Isbister’s criticisms demanded robust replies
and undoubtedly the ‘noise’ helped enormously
in spreading TME around the globe. Where there
is no argument there is often little interest. One of
the more colourful condemnations that I earned for
my impudence was from the then president of the
South African Surgical Association, who instructed
11/02/13 3:44 PM
 The low colorectal and coloanal anastomosis  15
his members to take no notice of ‘that fellow Heald,
he is a flamboyant charlatan’. I rather cherish this
particular accolade.
So it has indeed been down to friends and foes
along the way to make the final judgements. The fact
that TME is now a standard established operation
in virtually every country in the world implies that
the friends have tended to win.
John MacFarlane: a Canadian
in Basingstoke
Professor John MacFarlane, Professor of Surgery
at the University of British Columbia, Vancouver,
Canada, felt inclined to reject British and American
scepticism concerning the excellent reported out-
comes from Basingstoke. He offered to join the fray
by spending a sabbatical examining the methods
and validity of the data. In the event he recorded a
slightly greater favourable impact of ‘TME surgery’
on outcomes than had been reported, in both local
recurrence and survival data. His publication in the
Lancet, ‘Mesorectal excision for rectal cancer’,7 was
hailed by Professor Hans Troidl of Koln as the first
example in the history of surgery of one professor
visiting the unit of another to validate controversial
data and thus advance the craft of surgery.
Figure 1.17 illustrates his comparison between
Basingstoke patients treated with TME, without
radiotherapy or chemotherapy, compared with the
results of the Krook–Moertel publication extolling
100
Patients without Recurrence (%)
80
58.5%
60
40
37.3%
20
0 0
0 1 2 3 4 5
Years after Randomisation
Comparison of lifetables for recurrence-free interval between NCCGT series (left)
and this series of TME (right).
Figure 1.17. Our comparable Dukes “B” and “C” stage patients compared with North Central Cancer Treatment Group
patients.
HEBK001-C01_p01-30.indd 15
the extra benefits of radiotherapy and chemo-
therapy added to standard Mayo Clinic and other
North Central Cancer Treatment Group surgery.
The low colorectal and
coloanal anastomosis
The production and widespread use of disposable
circular staplers coincided with the emergence of
TME in the early 1980s. Completion of the anasto-
mosis involved insertion of a manual purse-string
in the anorectal stump. Various operative tricks
were developed to facilitate this often challeng-
ing undertaking but have now been superseded by
cross-stapling techniques and hand-sewn coloanal
anastomosis for the very lowest or to salvage rup-
ture of a cross-stapled anorectal stump.
During the mid-1980s it became apparent
that it was easier and quicker to perform a linear
staple line across the anorectal stump after the
routine washout of the lumen below a Satinsky
or Lloyd-Davis right-angled clamp. One of the
great advances in stapling was the ‘triple stapling
system’ described by my registrar at the time, and
subsequently my first colorectal colleague in Bas-
ingstoke, which I have named the ‘Moran triple
stapling technique’. The details are outlined in
Chapter 7. We have used this to facilitate TME for
more than 20 years.
Throughout and beyond the 1980s, a firm friend-
ship and cooperation developed with the stapling
100
78%
80
60
40
20
0 1 2 3 4 5
Years after Surgery
11/02/13 3:44 PM
 16  The evolution of a concept: the TME story
gun manufacturer Autosuture, which later became
Tyco and then Covidien. Mutual cooperation led to
sponsorship and support for workshops at home
and all over the world, and collaboration led to the
development of the TA45 (45 mm across) linear
stapler for the triple stapling technique (the origi-
nal technique was described with the TA55 stapler).
We advised that the average human rectum required
something more than the TA30 stapler while the
pelvis required something less than the TA55 stapler
for safe ­occlusion in the depths of the pelvis. This
was a fine example of clinical and industrial coop-
eration in the interests of better surgical technology.
Similarly, sharp dissection, which was the essence
of development of the holy plane, was increasingly
performed by pencil monopolar diathermy dis-
section, and modern Valleylab Triverse units have
evolved to maximize cut and coagulation and mini-
mize collateral damage.
Why is the plane ‘holy’?
The phrase ‘holy plane’ came from the practical reality
that this was the most satisfying interface to develop
and deliver ‘holy space’ – an idea that came to me
when visiting Jerusalem. It is a useful concept because
the line that is clearly visible around the mesorectum
on MRI, with appropriate traction and counter-trac-
tion and sharp dissection, turns into a potential space.
It has always seemed intrinsically probable to me that
this potential space, which allows the juxtaposed sur-
faces to move slightly in life, implies an encompassing
layer, which is likely to block angiogenesis, the impor-
tant concept of Judah Folkman, who I once had the
pleasure of meeting. Angiogenesis is the induction of
new blood vessels to nourish a spreading tumour, and
it does seem intrinsically likely that the areolar tissue
between embryologically different organs such as the
mesorectum and the surrounding nerve layer may
constitute an angiogenic barrier to the spread of can-
cer. This is little more than theory based on the unex-
pectedly good results and simple clinical observation.
The low and the ultra-low
Total mesorectal excision was a feasible proce-
dure for upper and mid-rectal cancers and led to a
smooth muscle tube that is ideal for stapling. There
emerged, however, various differences of degree of
difficulty according to the height of the cancer in
HEBK001-C01_p01-30.indd 16
relation to the build and sex of the patient. Thus, in
a slim woman it often proved to be easy to perform a
sphincter-preserving stapled anastomosis at or near
the dentate line, whereas some cancers in large men
as high as 7–8 cm could occasionally prove extremely
difficult to circumnavigate. The lowest tumours con-
tinue to be problematic, especially anterior tumours,
and the lower the anastomosis the greater the risk
of poor anal function and continence. This relates
particularly to the number of visits to the toilet each
day, to the occurrence of episodes of actual inconti-
nence, and also to the annoying symptom known as
‘clustering’, where multiple visits occur rather close
together. Unfortunately, increased use of preopera-
tive radiotherapy has greatly increased the incidence
of these symptoms over the past two decades.
Poor function has always been a worry with very
low anastomoses, and the disappointment of a
patient cured of rectal cancer but with worse bowel
symptoms after surgery is very problematic. Karanjia,
Schache and I published a comparison of the worst
function expected from an anastomosis at 3 cm from
the anal verge compared with one at 6 cm.8 This
important message justifies a subtotal mesorectal
excision if it is possible to clear the cancer in higher
tumours with a clear 5 cm of mesorectum. Even after
TME, careful preservation of a small rectal reservoir
is desirable when oncologically safe.
Basil Morson
During these exciting years of exploration of lower
and lower anastomoses, one of my early friends
and supporters was Dr Basil Morson, Head of
Histopathology at St Mark’s Hospital and successor
there to the famous Cuthbert Dukes of the Dukes
Classification. From the very beginning, Basil helped
the lift-off of the TME idea. ‘I’m a save-the-anus man’
he famously stated to the movie camera when the first
TME 16 mm film was produced in the early 1980s.
He also made a highly significant scientific obser-
vation: ‘The palpable lower edge of a rectal carci-
noma is almost always the microscopic lower edge.’
Various papers had demonstrated that intramural
downward spread from the lower margin of a rectal
cancer occurred only rarely and only in cases of a
particularly high malignant potential and a high
risk of coexistent metastatic disease. This state-
ment by a person so greatly respected by genera-
tions of young surgeons in a TME movie made at
11/02/13 3:44 PM
 Washing out the rectal stump against malignant implantation  17
St Mark’s was a huge boost.9 It reinforced the semi-
nal paper from the 1970s by Norman Williams and
colleagues who examined, and discarded, what used
to be called the ‘5 cm rule’ for distal rectal clearance
below a cancer.10
Therefore during the 1990s, we began to focus on
what we called the ‘close shave’ in rectal cancer and
published widely on this subject. From the practical
point of view, if one could get a finger and thumb
distal to the lower margin of the cancer, and a stapler
could be placed beyond this, there was a high prob-
ability that even margins of less than 1 cm would
not compromise cure, provided proper TME is per-
formed. Repeated distal margin frozen sections and
histological analysis of the distal ­‘doughnut’ from
the subsequent circular stapling firing confirmed
cancer clearance, allowing salvage of the sphincters
without sacrificing cure.
One of my highlights in 1996 was presenting the
Norman Nigro lecture at the American Society of
Colon and Rectal Surgeons.11 Norman Nigro revo-
lutionized the management of anal carcinoma from
major surgery (APE) to chemoradiotherapy alone.
Years later, with Norman sitting in the hall, I present-
ed my personal experience of 136 consecutive rectal
adenocarcinomas within 6 cm of the anal verge – that
is, very low cancers that would routinely all have had
an APE in that era. The rather provocative title ‘APE:
an endangered operation’ was the same title he had
used years earlier. It incorporated the concepts and
advantages of TME, as 77 per cent of the patients with
these ultra-low tumours had undergone sphincter-
preserving surgery and yet the local recurrence was well
below 5 per cent (confirmed on extended subsequent
follow-up). My hypothesis was that the vast majority of
abdominoperineal resections, by most surgeons, were
being performed for tumours that could safely have
been removed without sacrificing the levators or the
anal sphincters. My own very small number of APEs
had gone very badly, and this was widely quoted, par-
ticularly in Japan. The reasons for these poor APE out-
comes may have been partly technical, although it also
represented the worst small subgroup.
‘The sword of Damocles’:
anastomotic leakage
For all gastrointestinal surgeons, two major technical
issues haunt us: patients where delay has occurred in
the diagnosis of strangulating intestinal obstruction,
HEBK001-C01_p01-30.indd 17
and patients who have died from the consequences
of anastomotic leaks. In theory, both of these causes
of death could be eliminated, or markedly reduced,
by constant awareness and timely appropriate inter-
vention. In practice, especially with modern early
discharge, and discontinuity of care aligned with
suboptimal recording of patients’ temperature, pulse
and so on, patients still die from these causes.
Reoperation for leakage needs to be timely and
effective. The words of Rex Lawrie are worth reiter-
ating: ‘It is really important that the second opera-
tion should go well because the third and fourth
never work!’ This may not be absolutely true, but
it is important that the senior professional is always
there at that second operation.
Why Does Leakage Still Occur, and
Why Is It So Frequently Mismanaged?
It is well established that the risks of leakage
increase the nearer to the anal sphincters, with five
to ten times the risk for anastomoses within 6 cm
of the anal verge compared with higher anastomo-
ses. Contributing factors include haematoma for-
mation in the presacral space and blood supply at
the bowel ends. Over the years we published three
papers on this galling subject.13–15
The haunting memory that 3 of the first 100
TME patients died as a consequence of anastomotic
leakage probably led to very few in the subsequent
hundreds and largely a consequence of constant
anxiety and early intervention combined with a lit-
tle good fortune.
Faecal peritonitis arising within the pelvic cav-
ity, away from the pain-sensitive peritoneum of the
anterior abdominal wall, commonly goes unrecog-
nized or is treated by repeated doses of analgesia.
Indeed, anastomotic leaks are commonly confused
with myocardial infarction, pulmonary embolism
or other causes of serious illness with little abdomi-
nal symptoms or signs. My Dutch friends refer to
‘weekend tragedies’ because the operating team is
not working and the on-call team may have a lower
sensitivity to the possibility of faecal peritonitis and
less of a feeling of ‘ownership’ of the complication.
My various phases of defunctioning all or
selected patients finally settled to defunctioning all
patients whose anastomosis is low enough to have
followed a TME, somewhere between the dentate
line and about 4 cm above it. Loop ileostomy has
11/02/13 3:44 PM
 18  The evolution of a concept: the TME story
recently gained favour over my preference for right
­transverse colostomy, which I personally regret. I
consider a loop colostomy less likely to give small
bowel adhesions, to defunction more effectively
with little or no faecal residue between the stoma
and the join, and to obviate the risk of a high-
output stoma. This is particularly relevant with the
trend towards omitting mechanical bowel prepara-
tion, although the pendulum appears to be swing-
ing back in its favour for these low cancers.
Washing out the rectal
stump against malignant
implantation
My preference had always been to wash the rectal
stump below a clamp. Viable tumour cells have been
shown in animal models to produce tumours, espe-
cially in crushed devitalized tissue. Thus, a staple line
is excellent soil for a viable tumour seed to grow.
A paper from Sweden has reported a reduction in
the local recurrence from 10.2 per cent with no wash-
out compared with 6.0 per cent with a ­washout.12
Although it may be that washout is a surrogate marker
for attention to detail, this seems a simple procedure
with no complications and major potential benefits.
The Gina and Lennart story:
the emergence of magnetic
resonance imaging
The UK, Sweden and the Netherlands lead the
world in the use of MRI in staging and treatment
planning in visceral cancer management. All of this
is a direct consequence of the ‘TME story’. The two
radiologists who first grasped the key importance
of the precise visualization of the holy plane on
MRI were both intimately involved with TME at a
practical level, Gina Brown in the UK and Lennart
Blomqvist at the Karolinska Hospital, Sweden.
Similarly, my visit to Maastricht with the ‘TME
circus’ touched the work of Regina Beets Tan, who
has also become one of the world’s great MRI lead-
ers. All three had already recognized the potential
of MRI to delineate cancer and bowel wall mus-
cle, essential for T staging. The ability to delineate
the embryologically determined holy plane was of
even greater potential importance. Magnetic reso-
nance imaging could predict a clear margin in the
HEBK001-C01_p01-30.indd 18
mesorectal fascial plane (i.e. TME holy plane) or
direct more extended surgery, preoperative neoad-
juvant therapy or combinations of both for locally
advanced tumours where the potential circumfer-
ential margin was involved or threatened.
Magnetic resonance imaging has revolutionized
the comprehensive planning of treatment strategy,
is part of UK and many other guidelines, and has
been the ‘mother and father’ of the multidiscipli-
nary team concept. With the ability of all to view
the cancer and its surrounding structures, multidis-
ciplinary team decision-making is a major advance,
but the experienced surgeon’s finger remains a most
sophisticated probe for tumour height, the type of
distal margin, and the mobility of the tumour on
the puborectal sling.
Looking back, it is interesting to record how I
‘discovered’ Gina Brown in her formative years as a
research registrar. Janet (now Dame Janet) Husband,
a leading figure in diagnostic radiology, and a friend
from my days at Guy’s Hospital, gave me Gina’s name
as the person to talk on MRI at a meeting at the Royal
Society of Medicine. This was when I was President
of the Section of Coloproctology, where a paper was
to be read that pointed out how valueless MRI was
in the pelvis. Having foresight of this, I exercised
‘chairman’s prerogative’ and invited Gina to ‘trump’
this paper and tell us what she was achieving. This
underpins an important reality, special sequences are
required, fine (2–3 mm) slices, small fields, cuts per-
pendicular to suspect margins, and so on. ‘The devil,
as with TME itself, is in the detail’.
In tracking down Gina to put the record straight
for this meeting, I rang her hospital in Cardiff, where
the telephonist revealingly said: ‘Oh, I know where
she is – even this late at night. She is always work-
ing in her room in radiology.’ That single-minded
work ethic has driven her to the very front of one of
the world’s most exciting imaging advances – rectal
cancer treatment planning. It is thus through Gina
and Lennart that the history of MRI planning is so
intimately bound up with that of TME. So much of
the future will be about imaging that this reality is a
major part of our story.
The home front: Pelican
My operating career and TME drive would have
been shorter by at least 15 years if it had not been
11/02/13 3:44 PM
 ‘Metastatic’ total mesorectal excision to the liver and peritoneum  19
for the organizational skills of Sir Peter Michael,
creator of the Quantel Electronics Empire, Classic
FM and countless other enterprises that appealed
to his fertile imagination. He sculpted the Pelican
Centre, which gave an independent home, an office
and a personal ‘carer’ for me. Of all professionals,
surgeons seem to need these ‘carers’ most of all.
Jenny, Juliet and Emma have exercised the Pelican
hand on the rudder – their names come as worthy
successors to Jill, Rosemary and Pat in the twentieth
century. Throughout, the Medical Director Dr John
Fowler has overseen the key decisions and direction
of the whole foundation with unique wisdom. The
conquest of the world would certainly have faltered
without Emma and all at Pelican.
Pelican also expanded the horizons. The name
is short for ‘pelvic and liver cancer’. It sought to
encompass the two poll positions that our little Bas-
ingstoke Hospital was aspiring to in the world of sur-
gery – rectum and liver. At the same time it sought
to extend at least our intellectual involvement to the
management of prostate cancer. The disease was
essentially different – that which is lethal obscured
by red herrings, and the diagnosis by a fallacious
blood test, prostate-specific antigen (PSA). So it was
that the Pelican team branched out into focal ther-
apy for prostate cancer, yet another story that spins
off from TME. In particular we have focused on pre-
cision imaging, which has the potential to reduce so
much suffering, but that is another story!
Total mesorectal excision
and British medical politics
The greatest tragedy of the NHS is hugely pow-
erful managers who do not understand the once
powerful, but now impotent, consultants. Com-
munication blocked is progress deferred. Only
those who can build bridges are those who can
still achieve real improvement in hospital prac-
tice. Sir Michael Richards has this in spades.
Appointed as the first ‘cancer tsar’, he looked
around him through the fog of UK-critical Euro-
care data for projects to improve outcomes and
increase real cures. He took the trouble to travel
to Sweden to confirm our own wholly unlikely
story of Englishmen and Irishmen training
Swedes, and he returned with a burning determi-
nation to repeat and build on the TME workshop
HEBK001-C01_p01-30.indd 19
idea to encompass at the same time the concept
of multidisciplinary cancer board meetings.
Serendipity and the wisdom of Sir Peter
Michael produced at the Pelican a series of first-
class chief executive officers – first, Diane Hayter,
who put the show on the road, and then Chris
Beagley CBE. Chris brought a determination of a
naval ship’s captain and the negotiating skills of
a former civil servant at the Ministry of Defence
to bear at a critical moment. Sir Michael Richards
was so determined that his colleagues said ‘He’ll
get his way in the end’, and Chris delivered for
Pelican the biggest contract in its history and the
most outstanding government-backed training
scheme ever, the ‘multidisciplinary team TME
development project’.
All but one colorectal cancer multidisciplinary
teams in England attended between 2003 and 2007
(148 of 149). Out of all this came complete accept-
ance of the principle of multidisciplinary team dis-
cussion for every patient and mandatory MRI for
each patient. Real planning had started. After 8 years
Chris passed the helm to Sarah Crane, who has skil-
fully negotiated a mass of burgeoning bureaucratic
obstructions to clinical research, and she now keeps
Pelican securely on course.
‘Metastatic’ total mesorectal
excision to the liver and
peritoneum
Surgical expertise and endeavour propagate and
‘metastasize’, and thus Basingstoke has wandered
into two other fields where attention to detail and
surgical technique are key.
The first development was the ‘hepatic element’
of TME history with the appointment of Merv Rees
in the late 1980s to tackle the problem of color-
ectal secondaries in the liver. I had become aware
of the unexpected benefit attached to what preci-
sion hepatic surgery might deliver, especially on
encountering Johannes Scheele from Erlangen in
Germany. It was a pleasure to be a catalyst in Merv’s
friendship and cooperation with Johannes and ulti-
mately establishing Basingstoke as a world-class
centre for hepatic resection. In addition Merv has
spearheaded the educational centre, which has been
key to our home efforts in ongoing education and is
properly called ‘Merv’s Ark’.
11/02/13 3:44 PM
 20  The evolution of a concept: the TME story
Another key addition has been the treatment of
peritoneal malignancy, in particular pseudomyxoma
peritonei of the appendix. Visceral surgeons who
innovate find themselves a part of an international
club of eccentrics. My encounter commenced with a
telephone call from a general practitioner friend, Ste-
ve Tristram, who had been contacted by a childhood
friend of his wife whose young husband had been
diagnosed at open-and-close laparotomy ‘with a rare
kind of cancer called pseudomyxoma but nothing
can be done’. The answer to the question ‘Bill, can you
do anything?’ was ‘I can’t, but I know someone who
can – I heard him last week in Hong Kong.’ This cul-
minated in a visit to Basingstoke by Paul Sugarbaker
from the Washington Cancer Centre; Paul, assisted by
me and Brendan, performed a 12 h operation, which
gave the man 12 years of life. It was the first of what is
now approaching 1000 operative cases, and the name
Basingstoke has emerged once again, spearheaded by
Brendan and now Tom Cecil with three younger col-
leagues, Steve Arnold, Faheez Mohamed and Arcot
Venkat, joining the colorectal team in April 2009.
That first operation will be remembered for
many things, including three emergency visits
by the fire brigade as a consequence of fire alarm
activation by the high-powered diathermy smoke.
Worldwide total mesorectal
excision
National Total Mesorectal Excision
Projects
Perhaps the most extraordinary feature of the TME
story is the number of other countries that set up
national training projects in TME technique before
Britain. The Anglo-Saxon world was certainly the last
to show any enthusiasm. Professor Norman Williams
voiced dissatisfaction to the press at our failure in the
UK to introduce the training aspects formally at an
earlier stage. All the fundamental ideas were crystal-
lizing across the world from UK origins, but in other
cultures before ours – the ‘Bill, Phil and Gina show’
has extended to what the Canadians recently called
the ‘fab four’, embracing our Pelican revolution-
ary oncologist Rob Glynne-Jones. Excluded was our
new leader Brendan Moran, who stayed at home for
the wedding of Prince William and Kate Middleton.
Casting back to earlier days, it must be recorded that
HEBK001-C01_p01-30.indd 20
willingness to believe the unexpected and almost
unbelievable results and their potential benefit also
started in Norway and ­Sweden, although the impor-
tance of ‘Das Konzept’ was foreseen by Markus Buch-
ler in Germany. Much of the Scandinavian story has
already been told, along with some of the film scenar-
ios of operating rooms invaded by coffee machines
with Swedish and Norwegian surgeons eager to absorb
the TME message. This early enthusiasm was greatly
enhanced in both teachers and taught by the growing
involvement of Brendan Moran, whose ready Irish
charm and consummate surgical skill soon established
him as the future captain of the ‘Good Ship TME’
and ultimately the clinical lead in both the second
Danish national project and the somewhat belated
British Low Rectal Cancer National Development
Programme (LOREC).
Ireland
Many a rejected Englishman, smarting at the indiffer-
ence of his fellow countrymen, has found solace and
welcome across the Irish Sea. Conversely, Brendan,
like many Irish surgeons, found similar solace in leafy
Hampshire. Many Dublin surgeons, Liam Kirwan
in Cork and surgeons from across the Emerald Isle
embraced and practised TME at an early stage. Liam
Kirwan published figures identical to those from Bas-
ingstoke very soon afterwards, the first firm confir-
mation that our data were real.
To me, Irish TME philosophy runs thus: ‘Viola-
tion of the mesorectum is the clue to surgical failure
– treat it delicately like a virgin’.13
Germany
For me, the worldwide TME story begins in and ends
with Germany. An early great honour was that Markus
Buchler travelled to Basingstoke to visit one of our first
workshops back in the 1980s. This was followed by an
invitation from Bern, Switzerland to present the Koch-
er Memorial Lecture. Researching the life of Theodor
Kocher is inspirational: he was a brave honest surgeon
who believed in slow meticulous technique and the
primacy of precision, exactly like the TME dream.
Markus Buchler
Professor Markus Buchler rapidly recognized
the potential importance of TME, and our book
11/02/13 3:44 PM

Figure 1.18. Das Konzept.
Das Konzept Der Totalen Mesorektalen Exzision14
­(Figure 1.18) published the many implications of
new thinking. Markus regards cancer surgery as a
question of compartments and emphasized that
TME was the careful emptying of the central pel-
vic compartment. This amplifies the embryological
midline mesorectal entity and makes us aware that
each lateral compartment contains the internal
iliac vessels outside the nerve layer and a septum of
significant parietal fascia, which separates paired
parietal structures from the midline visceral block.
The visceral envelopes have arteries emerging from
the front of the aorta, and middle rectal arter-
ies from the internal iliacs are uncommon. At the
time the German book was published, Christophe
Maurer translated many chapters for me, and he
remains a leading German exponent of TME.
This first visit by Markus Buchler and his two
friends will never be forgotten – a totally unsuit-
able patient, no MRI, a ‘fixed cancer’ and no plan-
ning. Videos of the operation survive to illustrate
my ‘skeletons in the cupboard’ talk. These show
me cutting the left ureter while trying to clear the
cancer by excising the seminal vesicles. Lessons
were learned that day: we needed planning tools
(now MRI), and the ureters in such advanced cases
should always be stented.
More amusing was the cocktail party in the back
garden of our village home when Phil Quirke sat on
a pillar and cut up the specimen and passed around
the slices; the guests, champagne in their hands,
were offered these alternating with cocktail fancies
and sausages on sticks. My wife protested ‘What will
people in the village think?’
HEBK001-C01_p01-30.indd 21
Worldwide total mesorectal excision  21
Stunning variability between surgeons in
Germany: Paul Hermanek
Paul Hermanek has been called the ‘father of
­German histopathology’. He is, along with Cuth-
bert Dukes, Basil Morson and more recently Phil
Quirke, one of the all-time greats among ‘sur-
geons’ pathologists’ – those who involve them-
selves in the detail of the specimen, those whose
room is always open to the surgeon bearing fruits
fresh from the operating room of a recent battle
against cancer, eager for consultation and discus-
sion with a fellow warrior. Such pathologists are
one of the greatest weapons we have in the war
against cancer.
Paul made two seminal contributions in his
paper,15 curiously published in the Italian journal
Tumori. His observations were crucial: first, there
was a huge variability between operating surgeons
in their local recurrence rates; second, these varia-
tions were reflected in long-term survival. The clear
implication was that poorer surgeons were failing
to remove tissue potentially containing cancer. This
could then go on to metastasise.
Recent times in Germany
It is no surprise to me that, despite speaking no Ger-
man – except perhaps for ‘zug und gegen zug’ (‘trac-
tion and counter-traction’) – I now feel most wel-
come of all in Germany. Having grown up during the
Second World War and witnessed a Messerschmitt
109 shot down in anger, my life has gone full circle
– what a desperately sad and destructive century the
twentieth was for our great continent of Europe. At
least we have moved on and the TME story is one of
friendship containing many key German contribu-
tions. Professor Paul Hermanek’s observation of the
unique, totally unexpected variations in the local
recurrence rates in seven excellent German hospitals
was seminal to the concept. Equally important,
and still defying the understanding of some clini-
cal and medical oncologists, was Paul’s observation
that surgeons who achieved lower local recurrence
rates also had more true cures and fewer metas-
tases. This of course is critical to the importance of
TME, because the natural history of rectal cancer is
such that it remains locoregional in one central pel-
vic compartment for a very long time. During this
period a perfect TME will remove all the satellites of
cancer and thus cure the patient. Residual mesorec-
tum containing cancer or implanted cells on the raw
11/02/13 3:44 PM
 22  The evolution of a concept: the TME story
pelvic side-wall are extremely likely to lead to local
regrowth and ultimately death, from either direct
extension or metastases from the cancer left behind.
Friends in Heidelberg have been the princi-
pal basis of my ongoing practical teaching life in
­Germany in recent years, together with regular
visits to Erlangen, the home of Paul Hermanek.
Two-day craft workshops still seem the premier
teaching mode, while the modern video connectiv-
ity of high-definition laparoscopy stacks and the Da
Vinci Robot can potentially extend the experience
to larger and larger audiences around the world. In
April 2012 I was proud to be a part of the Heidelberg
surgery team transmitting an open TME by satellite
to the German Surgical Association in Berlin for
Markus Buchler’s presidential meeting.
Total mesocolic excision: Werner Hohenberger
The influence of TME extends beyond the rectum.
Professor Werner Hohenberger in Erlangen has put
down robust TME type principles for mesocolic
excision in colon cancer. Such principles do seem, to
rigid oncological surgeons like him, me and Brendan,
sometimes to have been compromised by some sur-
geons following the rise of minimally invasive sur-
gery. Ligation of the ileocolic vessels flush with prop-
erly exposed superior mesenteric vessels and intact
untorn colonic mesenteries are two examples.
It is a personal opinion that we are beginning to
see the rise of German surgery towards its formerly
dominant position before the tragedies of the 1930s
and 1940s. It is therefore a source of pride that the
widespread teaching of TME along practical work-
shop lines has been embraced so enthusiastically
in Germany and may become a part of this rise in
other surgical fields.
Joachim Strassburg
At an early stage in our discussions about how
unsatisfactory our technique for APE indeed was,
the ‘Berlin position’ entered the argument. This
was put forward by Professor Joachim Strassburg
from Berlin, who claimed that perfectly satisfactory
access to the back of the prostate and the challeng-
ing dissection between it and the front of the speci-
men could be effected without turning the patient.
Essentially the Berlin position meant a very steep
Trendelenburg with shoulder support and maxi-
mal flexion and abduction of the hips; the patient
was so steeply head-down that Joachim pointed out
HEBK001-C01_p01-30.indd 22
that one could stand a cup of coffee on the peri-
neum. This option in a slightly modified form is
now emerging again in the Netherlands under the
influence of Harm Rutten of Eindhoven. There is
no doubt that this difficult dissection in through
the perineal body with its proximity to the urethra
on the one hand and the front of the specimen on
the other would be very much better effected with-
out turning the patient if further studies show that
equally precise dissection is possible that way. The
question still remains open, and the most difficult
challenge is certainly the perineal body and the
neurovascular bundles subserving erection. The
problem is that there are no natural planes to guide
the surgeon and there is almost no room for error.
France
There are probably few stories of human endeavour
where the French have not added their own unique
dash of flair. So it is with our story. The word is
laparoscopy, and the minimally invasive hall of
fame is littered with the names of Frenchmen –
Marescaux, Leroy, Rullier, Panis.
Even before the laparoscopic revolution I over-
heard a most memorable compliment from Pro-
fessor Rolland Parc addressing a group of French
surgeons, describing TME as the ‘l’idée la plus
importante du monde’. He, and later Professor
Emmanuel Tiret, at the Hôpital St Antoine have
established a centre of excellence with TME at the
heart of its rectal cancer surgery. It was my privi-
lege to undertake a three-screen review of their
technique as long ago as 1995, and their APE results
suggest that they are well ahead of us when it comes
to avoidance of the ‘waist’ that bedevils APE.
The rise of laparoscopy has been gradual from
benign disease to malignancies, starting with small-
er, easier and earlier, and progressing with caution
to larger and deeper. Back in 1990, my videos of
sharp dissection under direct vision seem to have
inspired Professor Joel Leroy at a meeting in Tours:
‘I determined that day that we would reproduce pre-
cisely with the laparoscope what Heald was doing’.
Over the years this process has progressed like two
long-distance runners – me for example with three-
directional traction as the key tenet of teaching,
and him adding a fourth dimension because of the
pneumoperitoneum, and so on.
11/02/13 3:44 PM

Joel said: ‘I did probably the first laparoscopic TME
with coloanal anastomosis in November 1991 in a
young male patient [after chemoradiotherapy]. It was
a successful procedure and satisfactory oncologically’.
A postscript can be added in Joel’s own words that
provides perhaps a fantasy glimpse of the future.
I have news for you! I am writing for Archives
of Surgery the first NOTES transanal TME
without abdominal assistance and diverting
stoma using a particular procedure to mobilize
the sigmoid and descending colon and divide
the mesenteric vessels. I called the approach
PROGRESS – perirectal oncologic gateway
for retroperitoneal endoscopic single site
surgery: all the dissection is done by transanal
retroperitoneal approach.
Eligio Floscoli of Covidien has also been persuad-
ing me of the merits of dissecting upwards in the holy
plane from the perineum, along with John Marks
from Philadelphia, the delightful son of the illustrious
Gerald Marks. Who knows? The holy plane may per-
haps be accessed entirely by the ‘unholy orifice’! As we
go to press, the charismatic Spaniard Antonio Lacy
and I are also focused on this possibility.
Video-surgery
The primacy of surgical ideas being transmitted by
video is reflected in the rise of great surgical teach-
ing units with ever improving visual relay of ever
more surgical detail. Nowhere is this more evident
than in the magnificent Institut de Recherche contre
les Cancers de l’Appareil Digestif (IRCAD) Euro-
pean Institute of Tele Surgery (EITS) in Strasbourg.
Here I rejoice in the wonderful title of ‘Pope of the
Rectum’, a manifestation of the ready wit of Jacques
Marescaux, the great French surgical entrepreneur.
The virtuosity of Leroy and of a rich line-up of
invited surgeons provides unique training in the
potential of colorectal laparoscopic surgery – always
a wonderful weekend for everyone, faculty and visi-
tors alike. In the background is the comprehensive
Websurg providing accessible training on demand
from cyberspace. Extraordinarily the Marescaux
tentacles have replicated the IRCAD miracle in Tai-
wan and Brazil, where it is also my privilege to preen
myself as ‘Pope’. The world owes Marescaux a lot.
Elsewhere in France the saga has continued. An
open TME operation by myself in Bordeaux at the
HEBK001-C01_p01-30.indd 23
Worldwide total mesorectal excision  23
invitation of the great laparoscopic surgeon Eric
Rullier tested the idea that certain patients with
very low cancers could only be performed open. In
2010 Eric believed that this was true, but he now
believes that such patients do not really exist for the
highly experienced laparoscopist, except occasion-
ally for those with certain very large cancers.
If we extend this story to liver secondaries,
France can also boast one of the greatest of all liver
surgeons – Professor Henri Bismuth of the Hôpi-
tal Paul Brosse. He has also exchanged visits with
Basingstoke.
Sweden
Sweden has already featured in the story, but,
around the turn of the century, the Scandinavian
data collection was to prove a new weapon of enor-
mous power. Throughout my time on the council
of the Royal College of Surgeons, the strenuous
efforts of the maxillofacial surgeon John Williams
to introduce compulsory registration of cancer
and comprehensive clinical outcomes recording
in the UK had been sidelined by the Department
of Health. The ­manager-dominated NHS was far
more interested in politically sensitive issues such
as waiting lists. Not so the Swedes or Norwegians.
National training projects in both countries gath-
ered momentum, backed by compulsory pro forma
registration of all the clinically relevant informa-
tion – very similar to ‘Rosemary’s database’ back
home in Basingstoke. What was being recorded, at
last for a whole country, was the information that
cancer doctors were interested in – that is, those
things that might influence cure and patients’ suf-
fering. Such enlightened backing has reaped many
rewards. Most important was the ‘Martling papers’,
which demonstrated without doubt the impact of
our new workshops.16 More randomly, on a recent
visit to Gothenburg, which had formerly resisted
what Lars Pahlman called the ‘Heald wave’, real
evidence emerged of the value of irrigation of the
anorectal segment before stapled anastomosis.
As a believer in the potential of the NHS for
accumulating clinical data, I can only grieve that we
have not explored its potential in the way that they
have in Sweden. Fortunately the Association of Col-
oproctology of Great Britain and Ireland (ACPGBI)
is now addressing this matter urgently.
11/02/13 3:44 PM
 24  The evolution of a concept: the TME story
Norway
The Norwegian data have a special interest of their
own. As in other matters, the Norwegians have shown
remarkable independence and non-compliance with
the American National Institutes of Health (NIH)
consensus advice that led to neoadjuvant therapy
sweeping across the world. Their series reflects a very
small usage of radiation and reports results very little
affected thereby, and of course superior functional
results because low anastomoses and radiotherapy
are unhappy bedfellows. A substantial book was
written early on about the Norwegian project, and
Norway’s influence endures through the years.
The Netherlands
The formidable Dutch entrepreneurial surgeon
Cornelis (Cock) van der Velde first approached me
in 1993. At that time he had no real funding and was
indeed flying by the seat of his pants, with his dream
of improving cancer surgery. From our early meet-
ings came the Dutch TME trial, which has played
in the colorectal concert halls for almost 20 years,
generating more theses than any other project ever.
The trial was a development of Cock’s earlier D2
Radical Gastrectomy Cancer project, and the train-
Figure 1.19. Bill’s ‘buttocks’.
HEBK001-C01_p01-30.indd 24
ing component was already under way with the
Japanese colorectal surgeon Yoshihiro Moriya. He
visited me at home in Basingstoke and we operated
together several times. Memorable to me, and to the
patient who I later told, was his comment about the
male hypogastric nerves: ‘Englishman has very big
sex nerves’ he announced loudly to the operating
room. I declined to comment in the hope that we
might, if this view was to be widely promulgated,
thereby elevate the street credibility of the Eng-
lish. This may have succeeded as I heard it repeated
some years later. Both Yoshi and I criss-crossed the
traffic-packed roads of the Netherlands in a unique
enterprise to change surgical habits for a whole
nation of 20 million people. A posse of mentors
followed behind us providing surgical discipline
unique to the Netherlands. For me, a particular and
special Dutchman was a surgeon from the Academic
Medical Centre (AMC) in Amsterdam, Carlo Taat. It
was he who took me to every major hospital in the
Netherlands and attended every one of almost 50
demonstrations that I performed there. Together we
realized that learning TME is a progressive process,
the demonstration of the posterior dissection being
much easier than the front. The demonstration of
‘Bill’s billen’ (Dutch, ‘buttocks’) by a surgeon is per-
haps the first and easiest sign that he has grasped the
importance of holy plane dissection (Figure 1.19).
11/02/13 3:44 PM

His high intellect contributed much unrecognized
wisdom to the importance and impact of the Dutch
TME trial in the world of coloproctology. He later
drove me round Baden Wurtenburg in south-west
Germany on a similar mission. Sadly, I later went
to the Netherlands to say goodbye to him when he
decided to exercise the right of Dutch citizens to
end their own lives – his duodenum was obstructed
by an irremovable intractably painful malignancy.
As one of the two surgical trainers, I must con-
fess to disappointment at the high level of reported
margin involvement – 23 per cent – in the Dutch
data. So, although we cannot interpret the surgery
in the Dutch trial as being truly optimal TME
surgery, we salute Cornelis and Carlo’s courage
in tackling the enormous task of attempting to
convert an entire country’s surgical community
to long, slow tedious TME dissection and careful
planning.
The very holding of the workshops had a remark-
able impact, as analysed by Peeters (Figure 1.19).
Further major information is emerging after 12 years
of fastidious follow-up of this near-perfect prospec-
tive randomized controlled trial of radiotherapy ver-
sus no radiotherapy with no chemotherapy. There are
more people alive in the group that had not been irra-
diated than in those who had received short-course
high-dose radiation. This was despite about 6 per
cent of extra cancer cures, but these have been more
than cancelled out by additional deaths from other
causes – second malignancies in the irradiated pel-
vis, cardiovascular deaths, et cetera. No explanation
has emerged for the several largely undocumented
Figure 1.20. The impact workshops,
the Netherlands.
RT, radiotherapy; TME, total mesorectal excision.
HEBK001-C01_p01-30.indd 25
Worldwide total mesorectal excision  25
deaths that clearly followed radiotherapy, apart from
some second malignancies in the irradiated pelvis
and a hint of additional cardiovascular deaths. This
is surely a major challenge to the world of clinical
oncology to demand an answer. If we get such an
answer, then TME will make yet another chapter in
the cancer story.
Figure 1.20 shows that the greatest impact of
the Dutch TME trial was that the surgical train-
ing improved national outcomes immediately –
workshops are the thing.
Belgium
An interesting case report from the Procare Project
states:
Patient had had a sigmoid to anorectum
anastomosis . . . visit by me at 14 days: niggling
fever, normal water-soluble radial opaque
enema X-ray shows no leak. However, rectal
examination reveals the unique odour of
gangrene on the examining glove. Proctoscopy
shows the colon to be black and necrotic despite
the absence of a leak at that stage. Laparoscopy
was performed to mobilize the splenic flexure,
excise necrotic sigmoid and effect a new stapled
anastomosis. Satisfactory outcome.
This case emphasizes the importance of the tem-
perature chart, the need for constant awareness of the
risk of anastomotic failure, and the importance of
examining a suspect anastomosis with a proctoscope
11/02/13 3:44 PM
 26  The evolution of a concept: the TME story
to establish viability: viable ends mean that all faeces
must be washed through and the anastomosis can
remain truly defunctioned and not need to be taken
down.
Italy
As in so many aspects of life, Italy TME has
embraced TME with generosity. Many TMEs have
been performed in Rome, Milan, Bologna, Naples,
Palma and Bari.
One Armani-suited elder on Palma station greeted
me as ‘Signor Mesorectum!’
China and Japan
I have been made particularly welcome in these two
so different and important countries. Each deserves
a whole chapter in its own right, for rectal cancer is
common in both and extremely individual national
attitudes to the disease are apparent. Controversy
has raged for decades between Japan and the west
over the oncological importance of the internal iliac
and obturator nodes, the prophylactic removal of
which has been quintessentially Japanese but com-
pletely ignored by myself. My TME story is entirely
about what Markus Buchler calls the ‘central
compartment’. Hideaki Yano and Brendan Moran
has addressed this fascinating issue in Chapter 14.
China is perhaps the deepest mystery in the
world, and rectal cancer surgery is not excluded.
Each time I return from China I am a little more
confused. Several outstanding professors have
befriended me there, and there is no doubt that
TME has made an impact in Beijing, Shanghai,
Chengdu and Wuhan, in all of which I have done
open TME workshops. One most interesting dif-
ference from western practice is that low anas-
tomoses are often simply drained for 2 weeks or
more against the risk of faecal leakage but with
no diverting stoma created. Professor Gu at the
Beijing Cancer Hospital has undertaken exten-
sive TME histopathology micro-analysis and
established that small node positivity for cancer
is far more common than is generally believed – a
cogent further reason for the TME ‘oncological
envelope’ concept (Figure 1.21). It is better sim-
ply to regard mesorectal fat as ‘dangerous stuff ’.
HEBK001-C01_p01-30.indd 26
Figure 1.21. A perfect abdominoperineal excision is a total
mesorectal excision wrapped in levator and sphincters.
Hong Kong
Hong Kong has played a major part in TME, with
more than 20 visits, countless workshops and
video-operations, and the huge talent of Profes-
sor Michael Li of the Chinese University. Some of
the earliest laparoscopic versus open TME ‘con-
tests’ took place here, and Hong Kong has devel-
oped the most modern endoscopic laparoscopic
operating room, where all combinations of endo-
scopes are available at all times.
Russia, Poland and Eastern Europe
As I near the end of my career as a teacher of surgery,
the shift towards the eastern part of Europe has been
most noticeable. In 2010–2011 I was invited to Russia,
Poland, the Czech Republic, Hungary, the Ukraine,
Serbia, Slovenia (Figure 1.22) and Romania. The inci-
dence of colorectal cancer across the world is highest
of all in these countries, the top (or bottom) of the
league being Slovakia. The reasons are probably the
usual mix of dietary and genetic factors, but the need
for good affordable management plans with good
outcomes is nowhere more urgent.
The first visit to Moscow in 2009 was memo-
rable, with many hundreds of surgeons attending
from more than 80 cities in 9 countries. The patient
11/02/13 3:44 PM
 Worldwide total mesorectal excision  27

% 100

90
80
70
60
50
40
30
20
10

0
Local 5 year Permanent
recurrence survival stomas
(incl St IV)
%
Before After

Local recurrence 21 4

5 year survival (incl St IV) 34 77

Permanent stomas 67 18

All above p5,0.05; stage distribution and RT rate (54%

and 52%) unchanged. Figure 1.23. The Petrovsky Medal and Professorship.

Figure 1.22. Astonishing results in Slovenia: 195 patients

before and after two TME video workshops in 2009.
proudly announced to Russian television that he
was a wild boar hunter, and he has since sent me
more than 50 pictures of his continued activities
in this field after his successful operation. This visit
was the brainchild of Professor Petr Tsarkov, who
has become a firm friend and through whose medi-
ation Russia bestowed upon us its highest medical
honour, the Petrovsky Professorship and Medal.
These were formally conferred 2 years later in 2011.
They stand as a pivotal step forward in the interna-
tional spread of the TME idea (Figure 1.23).
The cost of the disease and the management of
failure is enormous, with the ever present nightmare
of massively expensive last-ditch treatments from
big pharma being simply unaffordable. Generally
these buy only weeks of rather unenjoyable life. The
real major solutions are earlier diagnosis and better
surgery.
Wroclaw, Poland
Some visits become fact-finding experiences for me.
In Wroclaw, Professor Marek Bebenek had lined up
eight operations to be performed over 2 days on
two tables side by side in one room. Four were to
be sphincter-preserving and four were to be APEs.
It is self-evident that every APE should encompass
a perfect TME (see Figure 1.21) but that the sphinc-
ters and perhaps the levators should be accurately
surrounding the distal part of the TME.
Torbjörn Holm had already suggested improv-
ing APE by turning the patient into the prone jack-
knife position, removing the coccyx, and doing the
job from behind. In Poland this was already hap-
pening and the words of Kocher from 1897 were
key: ‘The surgery of the sacrococcygeal region has
attained greater interest since it has been recognized
that . . . access to the pelvic organs from behind is for
many reasons preferable to that obtained from the
perineum.’
Marek Bebenek taught me how right Kocher’s
words were. I returned to the role of resident and
was taken through what I now like to call the
­Kocher–Holm APE. Torbjörn Holm’s own chapter
in this book is well illustrated with the emerging
excitement of one very special advantage of the
Kocher–Holm exposure. Whether Kocher himself
included in his ‘many reasons’ the ability to iden-
tify the neurovascular bundles as they converge to
the bulb of the penis is not recorded. This major
advance is indeed what we demonstrated and vid-
eoed for the very first time at one of our Pelican
operative workshops. Tom Cecil performed the
upper end and placed a clip on the hypogastric
plexus; later, with me at the audience end, the whole

HEBK001-C01_p01-30.indd 27 11/02/13 3:44 PM

 28  The evolution of a concept: the TME story
Figure 1.24. Neurovascular bundles after abdominoperineal
excision. Note the proximity to the divided right puborectal
muscle.
neuroanatomy at the back of the prostate was laid
bare, with visual continuity established by the clip
(Figure 1.24). The ongoing APE challenge still
remains and is covered in Chapter 8.
A ‘TME Blockbuster’ from Turkey
Students of TME now have access to a real treat:
the perfect companion to this book. Ayhan Kuzu,
Professor of Surgery from Ankara, with help from
many of our authors (Heald, Quirke, Brown, Rullier,
Holm), has created a virtual university course on
the subject in a pack of three DVDs. The con-
tents include most of our best videos plus Ayhan’s
HEBK001-C01_p01-30.indd 28
unique cadaver dissections and animations – all
flexibly coloured and labelled. In my opinion noth-
ing comparable has ever been achieved in the field
of teaching of surgical anatomy. I recommend it.
Please contact Ayhan Kuzu for more information
ayhankuzu@yahoo.com.
The USA and Canada
For this mighty continent and our impact upon it, a
whole book is required. We will highlight only a few
themes. First was the excellent surgical technique
I learned as a resident at the Ochsner Clinic in New
Orleans, where John Ray and his colleagues had estab-
lished one of the world’s first colorectal specialist
units. At that time, at the Mayo Clinic anything above
5 cm was still under the general surgeons. From Can-
ada came the all important intervention from John
MacFarlane from Vancouver, which was critical to the
establishment of our credibility; from Warren Enker
in New York came the same ideas presented robustly
and backed by immaculate data – plus an enduring
friendship for me and the still memorable operation
in Basingstoke where the left-handed Enker did the
patient’s left side and, I, right-handed, did the right side
(Figure 1.25). Along the way have been many interac-
tions with admired American friends – the Norman
Nigro lecture, visits and lectures at Memorial, Beth
Israel, Steve Wexner’s presidential invited lecture at the
Figure 1.25. Warren Enker from his
Ernest Miles Centenary Lecture.
11/02/13 3:44 PM

Society of American Gastrointestinal and Endoscopic
Surgeons, and so many more. More recently, in 2011
a major project involved us again in Toronto, where
all the concepts – MRI, surgical and pathological –
were promoted for the 12 million people of Ontario.
For years these concepts have been a key part of the
standard thinking of so many good American friends,
including Stan Goldberg, David Rothenburger and
Phil Paty. Professor Steve Wexner has done much for
international surgical training, with special empha-
sis on Central and South America, Russia and Israel.
Rob Maddoff and others are promoting these training
methods in their own constructive ways for the better-
ment of US cancer management.
2012 is a special year for TME as it will provide
the content for the Harry Bacon lecture at the spe-
cialist meeting of the American Society of Colon
and Rectal Surgeons in San Antonio, and later the
centenary cancer lecture of the American College in
Chicago. In summary, TME has established a firm
place in both British and American practice.
Anecdotal dramas from
the operating room
These are mostly tales that could have had a very
unhappy ending. On a visit to Istanbul, the elec-
tricity was cut off as my right hand was poised to
cut and we entered 65 minutes of total darkness. A
similar event occurred at a Basingstoke workshop,
when the building works for the Ark cut through
the power line and all electricity, including the
emergency reserve, disappeared. The visiting audi-
ence returned to their hotels but were called back
over an hour later when, mercifully, reconnection
was achieved; the patient lives 10 years on, after
a brief moment of fame on the front of the local
paper. In this case the blood supply to the rectum
had already been divided so that non-continuation
was not an option. Transfer to another hospital
would have involved descent of a stairwell with the
patient anaesthetized and the abdomen open or
packed shut, as the lift had also failed.
In another Basingstoke workshop I experienced
uncontrollable bleeding, subsequently discovered
to have been a result of inferior vena cava (IVC)
occlusion from a prophylactic IVC filter as the pre-
operative CT had shown common iliac thrombosis.
Total mesorectal excision had been performed and
HEBK001-C01_p01-30.indd 29
Conclusion  29
preparations had been made for anastomosis. The
pelvis was packed and Brendan completed the sur-
gery 2 days later. The patient is cured 8 years on.
Perhaps the most dramatic incident occurred in
front of one of my largest audiences ever, from all
around the Balkans. The city was Belgrade. Sanc-
tions were at work, and so the reserve diathermy
machine was of unspecified origin. It later tran-
spired that the settings had been known to no-one
and were five times the manufacturer’s recommen-
dations. The video shows that the camera recorded
something amiss as there was electricity in the air
and each touch of the diathermy makes the picture
jump. I point towards the right hypogastric nerve,
an arc of electricity leaps to ground on the patient’s
right external iliac artery and a fountain of blood
hits the light. There is an attempt to control the
flow, eventual common sense to ask for audience
support, and the appearance of a friendly vascular
surgeon and subsequently my carefully completed
TME. Many lessons were learned that day, and
the then 21-year-old woman still survives in good
health.
More quaintly, I have presided over the top end of
a widely transmitted colovaginal stapled anastomosis.
We did recognize and reverse it, so all was well. The
sharing of both triumphs and disasters with visi-
tors and audiences has perhaps been a bumpy road
towards better surgery around the world, but we claim
always to have been honest with our visitors.
Conclusion
This chapter is not finished. Perhaps it never will be.
There are many gaps in the detail and many individu-
als who have contributed so much along the way, and
so many patients who have been central to the story.
It is remarkable to see the same TME principles being
maintained and strived for as new technologies are
applied – laparoscopy, robotic, NOTES and all. The
cost-effectiveness of new expensive technologies
such as robots is debatable, but it is gratifying that all
are striving to achieve the same aim and are adding
another brick to the TME wall.
Total mesorectal excision has hugely stimulat-
ed the development of MRI cancer planning, has
added sophistication to scientific histopathology,
and has provided the most reliable and reproduc-
ible reference standard for surgical technique, and
11/02/13 3:44 PM
 30  The evolution of a concept: the TME story
each of these is constantly evolving over time. To
list all the major players along the TME pathway is
impossible, but together they have made the word
‘Basingstoke’ at the heart of any meaningful discus-
sion on optimal surgical technique for cancer and a
landmark in rectal cancer management.
To Our Registrars
Brendan and I share a sense of profound gratitude to
the many surgical registrars who have slaved for hours
over the human pelvis in the unique quest for greater
skill and understanding. We started to compile a list
and settled on avoiding the offence that an omission
might give. We mention one symbolic name – Marga-
ret Farquharson – because she probably slaved longer
than any of you. If you have read this far and feel a part
of the TME tale, then this ‘thank you’ is to you person-
ally and with great sincerity. You are the very stuff of
which the whole concept was constructed – painstak-
ing precise surgery combined with a passion for doing
things better.
References
  1. Heald RJ, Husband EM, Ryall RD. The mesorectum in
rectal cancer surgery: the clue to pelvic recurrence?
Br J Surg 1982; 69: 613–6.
  2. Asher R. Richard Asher Talking Sense. London,
Pitman, 1972.
  3. Morgado P. Total mesorectal excision: a misnomer for
a sound surgical approach. Dis Colon Rectum 1998;
41: 120–1.
  4. Heald RJ. Towards fewer colostomies: the impact of
circular stapling devices on the surgery of rectal can-
cer in a district hospital. Br J Surg 1980; 67: 198–200.
  5. Heald RJ. The ‘holy plane’ of rectal surgery. J R Soc
Med 1988; 81: 503–8.
  6. Heald RJ, Ryall RD. Recurrence and survival after total
mesorectal excision for rectal cancer. Lancet 1986; 1:
1479–82.
HEBK001-C01_p01-30.indd 30
  7. MacFarlane JK, Ryall RD, Heald RJ. Mesorectal exci-
sion for rectal cancer. Lancet 1993; 341: 457–60.
  8. Karanjia ND, Schache DJ, Heald RJ. Function of the
distal rectum after low anterior resection for carci-
noma. Br J Surg 1992; 79: 114–6.
  9. Karanjia ND, Schache DJ, North WR, Heald RJ. ‘Close
shave’ in anterior resection. Br J Surg 1990; 77: 510–2.
10. Williams NS, Dixon MF, Johnston D. Reappraisal of
the 5 centimetre rule of distal excision for carci-
noma of the rectum: a study of distal intramural
spread and of patients’ survival. Br J Surg 1983;
70: 150–4.
11. Heald RJ, Smedh RK, Kald A, Sexton R, Moran
BJ. Abdominoperineal excision of the rectum: an
endangered operation. Norman Nigro Lectureship. Dis
Colon Rectum 1997; 40: 747–51.
12. Kodeda K, Holmberg E, Jörgren F, Nordgren S,
Lindmark G. Rectal washout and local recurrence of
cancer after anterior resection. Br J Surg 2010; 97:
1589–97.
13. Reynolds JV, Joyce WP, Dolan J, Sheahan K, Hyland
JM. Pathological evidence in support of TME in the
management of rectal cancer. Br J Surg 1996; 83(8):
1112–5.
14. Buchler MW, Heald RJ, Maurer CA, Ulrich B. Das
Konzept Der Totalen Mesorektalen Exzision. Basel,
Karger, 1998.
15. Hermanek P, Wiebelt H, Staimmer D, et al. Prognostic
factors of rectal carcinoma: experience of the German
Multicentre Study. Tumori 1995; 81: 60.
16. Martling AL, Holm T, Rutqvist LE, Moran BJ, Heald RJ,
Cedemark B. Effect of a surgical training programme on
outcome of rectal cancer in the county of Stockholm.
Lancet 2000; 356: 93–6.
Further reading
Heald RJ, Leicester RJ. The low stapled anastomosis. Dis
Colon Rectum 1981; 24: 437–44.
Karanjia ND, Corder AP, Bearn P, Heald RJ. Leakage from
stapled low anastomosis after total mesorectal excision for
carcinoma of the rectum. Br J Surg 1994; 81: 1224–6.
Schache D, Stebbing A, Heald RJ. Management of the
pelvic space following low anterior resection. Aus N Z
J Surg 1989; 59: 339–42.
11/02/13 3:44 PM

Anatomy of the rectum, anal canal
and pelvic floor
Thilo Wedel
Introduction
Undoubtedly, anatomy is the mother discipline
of all surgical interventions. This general notion
holds especially true for rectal cancer surgery, as
many of the successful advances in surgical treat-
ment of rectal cancer have been derived from ana-
tomical considerations. In fact, revisited studies of
the anatomy of the rectum, anal canal and pelvic
floor have led to substantial procedural modifica-
tions for both anterior rectal resection and ab-
dominoperineal excision.
One of the seminal anatomical contributions
with regard to rectal cancer surgery has been the
clear description of the major routes of lymphatic
cancer spread. Since the introduction of total me-
sorectal excision (TME), including the removal
of the rectum together with its surrounding lym-
phatic vessels and lymph nodes, local recurrence
rates have been considerably reduced. This con-
ceptual change was advocated more than 100 years
ago, exemplified by Berkeley Moynihan (1908),
who stated that ‘we have not yet sufficiently real-
ised that the surgery of malignant disease is not
the surgery of organs – it is the applied anatomy of
the lymphatic system.’
Another milestone set by anatomical consid-
erations has been the preservation of functionally
HEBK001-C02_p31-51.indd 31
2
relevant structures located in close topographi-
cal proximity to the rectum. Comparable to the
nerve-sparing procedures introduced in thyroid
gland surgery and radical prostatectomy, preser-
vation of autonomic nerve plexi passing adjacent
to the rectum has become an important issue to
improve postoperative outcomes with regard to
urogenital functions. Thus, from the anatomical
point of view, rectal cancer surgery comprises at
least a twofold challenge: oncologically curative
removal of the rectum along the mesorectal plane,
and at the same time optimal preservation of the
surrounding structures, in particular the nerves
responsible for urinary continence and sexual
function. This chapter focuses on the anatomy of
the organs to be removed and on the anatomy of
the structures to be preserved during rectal cancer
surgery.
With regard to the anatomical nomenclature,
one has to be aware that over the past few decades
many different names have been given to the same
structures in the anatomical and surgical literature.
These differing nomenclatures have led to ongoing
confusion and, in some instances, controversies re-
garding the exact topography or even the existence
of a given anatomical structure. Irrespective of these
terminological issues, however, a general agreement
has been reached concerning the most relevant
11/02/13 4:31 PM
 32  Anatomy of the rectum, anal canal and pelvic floor

anatomical key landmarks required to meet the ex-

pectations of modern rectal surgery.

Embryology cloacal membrane

allantois

urorectal septum
cloaca
Development of the Rectum hindgut
and Anal Canal
The gastrointestinal tract is an endoderm-derived
structure passing through the body cavity as a primi-
tive gut. The primitive gut can be subdivided into
the foregut, midgut and hindgut, which are all con-
nected to the inner body wall by mesenteries serving
as access routes for blood and lymphatic vessels. The proctodaeum

hindgut includes the distal third of the transverse

colon, the descending and sigmoid colon, and at its
most distal end the rectum and upper anal canal.
The anorectal tube opens into a dilated pouch
termed the endodermal cloaca. Initially the cloaca
corresponds to a common cavity in the develop-
ment of both urogenital and gastrointestinal or-
gans. The Wolffian and Müllerian ducts and the
bladder with the allantois and ureters open into
its ventral portion and the anorectal tube opens urogenital membrane urinary bladder
into its dorsal portion. The cloaca is closed by the perineum urorectal septum
cloacal membrane formed by an inner endoder-
mal layer and an outer ectodermal layer. From anal membrane anorectal canal
outside, the cloacal membrane displays a depres-
sion lined by ectoderm and named proctodaeum
(anal groove). Figure 2.1. Embryonal development of the cloaca. The
cloacal cavity is divided by the primitive urorectal septum
At a later stage, the common endodermal
and separated during the seventh embryonal week into an
cloaca is divided by the primitive urorectal sep-
anterior part (urogenital sinus) and posterior part (anorectal
tum into an anterior part (urogenital sinus) and canal). (Reproduced from Schünke, M. et al., Prometheus
posterior part (anorectal canal) (Figure 2.1). Atlas of Anatomy, Vols. 1 and 2. Stuttgart, Germany,
The urorectal septum is composed of mesenchy- Thieme Publ. 2007/2009, with permission.)
mal tissue growing downwards to fuse with the
cloacal membrane, which is then also separated
into a urogenital and anal membrane. The fu- epithelium along the anorectal canal occurs in a
sion area between the urorectal septum and the craniocaudal direction, starting inside the anal
cloacal membrane corresponds to the primitive canal and proceeding externally.
perineum, which in turn will form the perineal
tendinous centre or perineal body. After degen- Relevance for Rectal Cancer Surgery
eration of the anal part of the cloacal membrane,
the upper anal canal derived from the endoderm The significance of embryological considerations for
is continuous with the lower anal canal derived rectal cancer surgery comes mainly from the observa-
from the ectoderm. Studies have shown that tion that the vascular and lymphatic supply of almost
epithelial differentiation from cylindrical single- the entire rectum is derived from visceral blood and
layered rectal epithelium to keratinized squamous lymphatic vessels travelling within the mesorectum.

HEBK001-C02_p31-51.indd 32 11/02/13 4:31 PM


This notion has been particularly emphasized by
F. Stelzner, who subdivided vertebrates into two
separate organisms based on developmental studies,
namely into an inner ‘visceral individuum’ enveloped
by an outer ‘somatic individuum’.1 In the visceral in-
dividuum, all organs are singular (e.g. stomach, liver,
spleen, intestines, rectum), with singular blood and
lymphatic vessels; in the somatic individuum, the or-
gan units are bilaterally symmetric (e.g. two kidneys
and ureters, two gonadal systems, two levator ani
muscles, two semicircles of external anal sphincter).
Accordingly, the blood and lymphatic supply of the
rectum including the upper anal canal is provided by
the visceral individuum (superior rectal artery, lym-
phatic drainage towards the inferior mesenteric lymph
nodes), whereas the pelvic floor muscles including the
external anal sphincter are supplied by bilateral sym-
metric vessels (internal iliac and pudendal vessels)
derived from the somatic individuum. The border of
these two embryologically different ‘individuals’ re-
sides along the transition zone between the upper and
lower anal canal at the level of the dentate line.
Moreover, embryological studies have highlighted
the fact that not only the rectum but also its vascu-
lar and lymphatic supply are commonly ensheathed
by a fascial system termed the mesorectum, which
remains clearly discernible in postnatal life. The me-
sorectal fascia represents the embryological delinea-
tion of the visceral from the somatic individuum con-
fining the main route of rectal cancer spread. Thus,
precise surgical dissection along these embryologi-
cally defined planes will enable an oncologically safe
removal of the specimen with minimal vascular and
nerve damage.
RECTUM AND ANAL CANAL
The rectum and the anal canal are the last segments
of the gastrointestinal tract responsible for mediat-
ing stool continence and coordinating the defeca-
tion process. Under normal conditions, the rectum
is empty and the anal canal is closed by means of
the anal sphincter complex and the haemorrhoidal
plexus. Filling of the rectum by mass movements
from the descending and sigmoid colon initiates the
defecatory reflex, which induces relaxation of the
anal sphincters, contraction of the rectal wall and
deflation of the haemorrhoidal cushions to allow
the passage of stool.
HEBK001-C02_p31-51.indd 33
RECTUM AND ANAL CANAL  33
The recto-anal segment is 15–20 cm long and ex-
tends from the rectosigmoid junction adjacent to
the promontorium down to the anal orifice. It cor-
responds to the dorsal intrapelvic organ compart-
ment descending in front of the concave sacrum
(sacral flexure) towards the anal hiatus of the pel-
vic floor. Due to the contraction of the puborectal
sling, the anal canal is angled in a dorsal direction
at the anorectal junction (perineal flexure), form-
ing an angle of 90–1008 with the rectum (anorectal
angulation) (Figure 2.2).
Rectal Ampulla
The upper part of the rectum has the same diam-
eter as the sigmoid colon (approximately 4–6 cm),
but the lower part of the rectum widens to form
the dilated rectal ampulla, with a diameter of up
to 16 cm, depending on how full it is. The rectal
wall differs morphologically from the colon by the
confluence of taeniae coli to a continuous longi-
tudinal smooth muscle layer, permanent semilunar
transverse folds, and the absence of fatty appendi-
ces epiploica.
Most of the rectum is not covered by peritone-
um, and thus the rectum is predominantly an extra-
or subperitoneal organ. Only the upper two-thirds
of the ventrolateral rectal wall is directly related to
the peritoneum, which reflects on to the bladder
and seminal vesicles in males (rectovesical pouch)
and on to the uterus and posterior vaginal fornix in
females (recto-uterine pouch, commonly known as
the pouch of Douglas).
Anal Canal
The rectal ampulla narrows at the level of the anorec-
tal junction and becomes the anal canal (pars analis
recti). The anal canal extends down and backwards
to the anal orifice and is 2.5–4 cm long. The anal ca-
nal is where the gastrointestinal tube of endodermal
origin (‘visceral individuum’) fuses with the skin
of ectodermal origin and the surrounding striated
pelvic floor and anal sphincter muscles (‘somatic
individuum’). Thus, the anal canal represents the
topographical junction where the nerve, blood and
lymphatic supplies of visceral and somatic structures
merge and overlap. Accordingly, the anal canal is
11/02/13 4:31 PM
 34  Anatomy of the rectum, anal canal and pelvic floor
haemorrhoidal
external anal sphincter plexus
(deep part)
dentate line
(anal valves & crypts)
external anal sphincter
(superficial part)
external anal sphincter anoderm
(subcutaneous part)
perianal skin intersphincteric groove
(anal verge)
divided into an upper and lower segment separated
by a transitional zone at the dentate line.
Segments of the anal canal
The upper segment of the anal canal extends from
the anorectal junction, defined by the superior bor-
der of the external anal sphincter (anorectal ring) to
the transitional zone. The inner lining consists of a
pink-coloured mucosa with single-layered cylindri-
cal epithelium (zona colorectalis).
At the transitional zone (zona transitionalis),
the wet mucosa changes into a dry stratified sq-
uamous non-keratinized epithelium displaying
a ­histological mosaic of cylindrical, cubic and
flat epithelial cells. The transitional zone exhibits
8–12 readily discernible vertical anal columns
(Morgagni) containing terminal branches of the su-
perior rectal artery. Between these anal columns ex-
tend anal sinuses that form pocket-like folds at their
lower ends, the anal valves or crypts. The circular
line of alternating anal columns and anal valves cor-
responds to the dentate line (pectinate line, crypt
line) considered to be the junction between the
HEBK001-C02_p31-51.indd 34
Figure 2.2. Rectum and anal
canal. The frontal section shows
internal anal sphincter
the inner relief of the rectal ampulla
and anal canal, and cross-sections
conjoint longitudinal
muscle of the haemorrhoidal plexus,
the internal and external anal
proctodeal glands
sphincters and levator ani muscle.
(Reproduced from Schünke, M.
et al., Prometheus Atlas
of Anatomy, Vols. 1 and 2.
Stuttgart, Germany, Thieme Publ.
2007/2009, with permission.)
endodermal (cloacal) and ectodermal (proctodeal)
parts of the anal canal.
The lower segment of the anal canal extends from
the dentate line to the anocutaneous line and cor-
responds to the anoderm lined by a non-keratinized
stratified squamous epithelium (zona squamosa).
The anodermal skin is devoid of glands and hairs but
richly equipped with sensory somatic nerve endings,
making it very sensitive to touch, pain and tempera-
ture. At the lower end of the anal canal, an anal inter-
sphincteric groove (anal verge) is palpable between
the bulge of the internal and external anal sphincters.
Whereas the ‘surgical’ anal canal is defined by the en-
tire segments from the anal ring to the anal verge,
the ‘anatomical’ anal canal is confined to the lower
segment and involves only the anoderm.
At the anal orifice, the anodermal skin changes
into true skin. The hairless perianal skin is of a dull
brown colour and displays radial folds caused by
the contraction of the corrugator ani muscle. The
skin contains sweat, sebaceous and apocrine glands
and is supplied by perianal blood vessels originat-
ing from the inferior rectal artery.
11/02/13 4:31 PM

Haemorrhoidal plexus
The haemorrhoidal plexus corresponds to a vascular
network extending within the submucosa of the up-
per anal canal best described as corpus cavernosum
recti (anulus haemorrhoidalis, glomera venosa haem-
orrhoidalia). The submucosal vascular plexus is char-
acterized by arteriovenous anastomoses and dilated
veins due to sphincter-like constrictions that provide a
taut elastic apposition of the anal columns and thus an
air- and liquid-tight closure of the anal canal.
The haemorrhoidal plexus is supplied by branch-
es from the superior rectal artery, which reach the
corpus cavernosum recti from the right (7 and 11
o’clock, lithotomy position) and left (3 o’clock)
sides. The blood is drained by veins penetrating
through the internal anal sphincter and collected in
the external rectal venous plexus. Due to the trans-
sphincteric blood drainage, the degree of filling of
the haemorrhoidal plexus is determined primarily
by the contraction of the internal anal sphincter.
Normally the draining veins are compressed by the
resting tone of the internal anal sphincter, result-
ing in a physiological cushion-like swelling of the
haemorrhoidal plexus. Relaxation of the internal
anal sphincter during defecation allows proper
emptying and down-sizing of the haemorrhoidal
plexus for the passage of stool.
Anal Sphincter Complex
The anal sphincter complex is composed of two
concentric muscles: the internal anal sphincter
composed of smooth musculature derived from
the rectal wall, and the external anal sphincter
composed of striated musculature, which is in-
timately fused with the surrounding muscles of
the pelvic floor.
Internal anal sphincter
The internal anal sphincter consists of circular
smooth muscle bundles and corresponds to a distal
thickening of the circular muscle layer of the rectal
wall. The ring-shaped muscle is 5–8 mm thick and
2–3 cm long. In relation to the anal canal, the inter-
nal anal sphincter extends from the anorectal junc-
tion down to the anocutaneous line, with the most
prominent part projecting on to the anoderm. The
subcutaneous part of the external anal sphincter
overlies the lower part of the internal sphincter, cre-
HEBK001-C02_p31-51.indd 35
RECTUM AND ANAL CANAL  35
ating the intersphincteric groove (anal verge). Due to
its permanent involuntary contraction, the internal
anal sphincter is readily palpable as a rigid cylinder, in
particular when the striated external anal sphincter is
completely relaxed (e.g. under anaesthesia).
The longitudinal muscle layer of the rectal wall
also continues distally into the anal sphincter com-
plex. Smooth muscle bundles descend between the
internal and external anal sphincter, towards the
perianal region, and are joined by striated muscle
fibres from the puborectal muscle (conjoint longi-
tudinal muscle). Distally, the muscle fibres diverge,
become fibro-elastic and insert into the perianal
skin producing radial wrinkles (corrugator ani
muscle). The most peripheral muscular septa radi-
ate outwards and pass between the subcutaneous
and superficial parts of the external anal sphinc-
ter into the ischioanal space. These fibres insert in
the superficial perineal fascia and contribute to the
separation of the ischioanal space from the subcu-
taneous perianal space.
External anal sphincter
The external anal sphincter surrounds the internal anal
sphincter, but both muscles are separated by connec-
tive tissue (intersphincteric plane). The external anal
sphincter forms an elliptical cylinder approximately
15 mm thick and is divided by septa into three parts.
Although the external anal sphincter is a striated skel-
etal muscle, its fibres are composed mainly of slow-
twitch type I fibres mediating prolonged contractions
suitable for maintaining an adequate basal tone.
The deep part of the external anal sphincter is the
thickest and most cranially located segment delineat-
ing the anorectal ring. Its fibres blend with the pub-
orectal muscle and are not attached posteriorly to the
coccyx, and so this muscular portion is able to follow
the contraction of the puborectal muscle anteriorly
to create the anorectal angle. The superficial part is
attached firmly to the perineal tendinous centre an-
teriorly and to the anococcygeal ligament posteriorly
and is therefore elliptical in shape. The subcutaneous
part circumscribes the anal orifice and extends deep
to the skin below the lower border of the internal anal
sphincter. Smooth muscle bundles from the conjoint
longitudinal muscle intermingle with striated mus-
cle fibres of the external anal sphincter. In males, the
three parts of the external anal sphincter are of equal
dimension along the circumference; in females, the
external anal sphincter muscle is reduced anteriorly
11/02/13 4:31 PM
 36  Anatomy of the rectum, anal canal and pelvic floor

to about one-third of its posterior thickness, in par-
ticular due to its less developed deep part.
Perirectal Fascia and Spaces
Comprehensive understanding of the topographi-
cal anatomy of fascia and spaces that surround the
rectum is of utmost importance and an essential
prerequisite for rectal cancer surgery. Since the in-
troduction of the TME procedure, it has become ob-
vious that successful surgery depends first and fore-
most on mobilizing the rectum along the correct
planes to achieve both oncologically safe margins
and optimal preservation of urogenital functions.
Initial attempts to describe the perirectal fas-
cial anatomy have led to differing nomenclatures
and controversies regarding the exact topography
of those fascial structures enveloping the rectum.
Macroscopic dissection studies on fixed and fresh
specimens, histological and immunohistochemi-
cal studies and subtle intraoperative observations
have shown, however, that the system of intrapelvic
fascial layers allows clear identification of perirectal
spaces suitable for proper and safe mobilization of
the rectum (Figure 2.3).
Rectal fascia/mesorectum
The inner surface of the pelvic wall, including the pel-
vic muscles (internal obturator, levator ani, coccygeal

middle rectal
peritoneum artery

inferior hypogastric
plexus
rectal
presacral
fascia
fascia

pelvic splanchnic
nerves

superior rectal hypogastric

artery nerve

retrorectal Figure 2.3. Perirectal

space spaces, mediosagittal
section of male pelvis,
presacral space
with presacral vessels
left view. The rectal
fascia and presacral
fascia are highlighted to
illustrate the perirectal
mesorectum with tissue (mesorectum)
lymphatic vessels
and both the retrorectal
and presacral spaces.
Note that the retrorectal
rectoprostatic septum rectosacral fascia
(Denonvillier´s fasica)
,
(Waldeyer s fascia)
space is free of blood
vessels and nerves and
corresponds to the
anococcygeal correct surgical plane
ligament
for mobilization of the
ischioanal space rectum during total
mesorectal excision.
perineal body (Reproduced from
Schünke, M.
et al., Prometheus
Atlas of Anatomy, Vols.
1 and 2. Stuttgart,
Germany, Thieme
Publ. 2007/2009, with
permission.)

HEBK001-C02_p31-51.indd 36 11/02/13 4:31 PM

 RECTUM AND ANAL CANAL  37

and piriformis muscles) are covered by the parietal
pelvic fascia. The visceral pelvic fascia (endopelvic
fascia) ensheathes the pelvic organs, including the
rectum. In contrast to urogenital pelvic organs, the
rectum exhibits an almost completely closed annular
envelope called the rectal fascia (‘proper’ perirectal
fascia, fascia propria recti). The rectal fascia corre-
sponds to a rather thin connective tissue sheath and
constitutes a morphological barrier, thereby prevent-
ing early penetration of rectal cancer. For this reason,
it has also been described by Stelzner as a ‘delimiting’
rectal lamellae (‘rektale Grenzlamellen’).1
An alternative, clinically widely used term for
the rectal fascia is ‘mesorectal’, introduced by sur-
geons to describe the complete removal of the
perirectal tissue together with the rectum during
TME. This surgical concept is based on the ob-
servation that the mesorectum – like the true me-
senteries of the small and large bowel – ensheathes
the tissues harbouring the major routes of blood
vessel supply and lymphatic drainage of the corre-
sponding bowel segment. In fact, the mesorectum
surrounds the fatty perirectal tissue that contains
the branches of the superior rectal artery and the
perirectal lymph nodes and vessels draining in a
cranial direction towards the inferior mesenteric
lymph nodes.
The perirectal tissue enclosed by the mesorectum
is most developed at the dorsal aspect of the rectal
wall, producing two bulges (‘mesorectal cheeks’).
Anteriorly, the mesorectum border is the rectogeni-
tal septum (Denonvilliers’ fascia), where the per-
irectal tissue is much thinner. The dorsal and ven-
tral parts of the mesorectum resemble a continuous
plane, but laterally the rectal fascia is not completely
closed. At these sites the annular pattern of the me-
sorectum is interrupted bilaterally due to the re-
flection of the rectal fascia towards the pelvic wall
(lateral rectal ligaments, rectal pedicles) to give ac-
cess for blood vessels and autonomic nerves passing
from the inferior hypogastric plexus to the rectal
wall. As a consequence, surgical mobilization of the
rectum along the mesorectum requires sharp dissec-
tion laterally, while posteriorly and anteriorly it can
be achieved by making use of ‘self-opening’ surgical
planes (Figure 2.4).

ureter
(duplex)

superior hypogastric
plexus

ovarian superior rectal

vessels presacral
fascia artery

presacral space retrorectal

with presacral vessels space

hypogastric rectal
nerve fascia

mesorectum

Figure 2.4. Perirectal spaces, dissected female pelvis, cranial view. The right forceps is inserted into the rectum and pushed
forward to illustrate the rectal fascia that surrounds the perirectal tissue (mesorectum) and contains the superior rectal artery
(red vessel loop). The left forceps grasps the presacral fascia that separates the retrorectal space from the presacral space.
Note that the superior hypogastric plexus (yellow strip) and hypogastric nerves are embedded into and extend along the
presacral fascia. (Reproduced from Schünke, M. et al., Prometheus Atlas of Anatomy, Vols. 1 and 2. Stuttgart, Germany,
Thieme Publ. 2007/2009, with permission.)

HEBK001-C02_p31-51.indd 37 11/02/13 4:31 PM

 38  Anatomy of the rectum, anal canal and pelvic floor
superior rectal
artery
pelvic splanchnic
nerves
hypogastric
nerve
inferior hypogastric
plexus
middle rectal
artery T-junction
neurovascular
bundles
Figure 2.5. Perirectal spaces, transverse section of male pelvis, cranial view. The rectal fascia and presacral fascia are highlighted
to illustrate the perirectal tissue (mesorectum) and both the retrorectal and presacral spaces. Anteriorly the rectal fascia is
bordered by the rectoprostatic septum (Denonvillier’s fascia). Laterally the rectal fascia is pierced on both sides by rectal nerves
diverging from the inferior hypogastric plexus and by small vessels of the middle rectal artery (rectal pedicles, T-junction). Nerves
from the inferior hypogastric plexus continue in an anterior direction as neurovascular bundles to supply the urinary bladder,
prostate and seminal vesicles.
Lateral rectal ligaments/rectal pedicles
On both sides, the rectum is loosely connected to
the pelvic wall by condensed connective tissue,
traditionally described as lateral rectal ligaments.
Originally these were considered to function as
true ligamentous structures to support the rectal
ampulla above the pelvic floor. From anatomical
and developmental studies, however, it has become
obvious that these ligaments do not provide sub-
stantial mechanical fixation but serve primarily as
access routes for the vascular and nerve supply of
the rectum, leading to alternative and more appro-
priate terms, such as rectal pedicles, rectal stalks
and ‘paraproctial’ compartment.
The rectal pedicles contain small-sized branches
from the middle rectal arteries (if present) and the
autonomic nerve fibre branches (rectal nerves) that
originate from the dorsolaterally located inferior
hypogastric plexus and traverse medially to enter the
rectal wall. This connection between the rectal wall
and the parietal pelvic fascia harbouring the inferior
hypogastric plexus is also called the T-junction. As
HEBK001-C02_p31-51.indd 38
presacral space
with presacral vessels
presacral
fascia
retrorectal
space
rectal
fascia
mesorectum with
lymphatic vessels
rectoprostatic septum
(Denonvillier´s fasica)
seminal vesicles
prostate
urinary bladder
mentioned above, for complete mobilization of the
rectum, the T-junction has to be sharply divided on
both sides at the level of the rectal pedicles. Care
must be taken, however, to stay rather close to the
rectum to avoid damage to the inferior hypogastric
plexus, thereby preserving sexual function and uri-
nary continence (Figure 2.5).
Presacral fascia
Behind the rectal fascia (posterior mesorectum)
extends another fascial envelope following the con-
cavity of the sacrum, the presacral fascia. The pre-
sacral fascia is part of the parietal pelvic fascia that
covers the periosteal surface of the sacrum dorsally
and reflects laterally towards the rectogenital sep-
tum (Denonvilliers’ fascia). The rectal fascia and
presacral fascia are clearly separated from each oth-
er by the retrorectal space. When descending down
to the pelvic floor, however, approximately at the
level of the fourth sacral vertebra, the rectal fascia
fuses with the presacral fascia. This connective tis-
sue bridge between the rectal and presacral fascia
11/02/13 4:31 PM
 RECTUM AND ANAL CANAL  39

hypogastric
nerve

pelvic splanchnic
nerves

inferior hypogastric
plexus

neurovascular
bundles middle rectal
artery

urinary bladder
T-junction presacral
fascia
seminal vesicles

prostate

rectal
fascia

rectoprostatic septum mesorectum superior rectal

,
(Denonvillier s fascia) artery

Figure 2.6. Perirectal spaces, sagittal section of male pelvis, left view. The rectum and the surrounding mesorectum are
pushed towards the contralateral side to illustrate the course of the autonomic pelvic nerves along the pelvic wall. The
hypogastric nerve and the pelvic splanchnic nerves join the extensive network of the inferior hypogastric plexus. Rectal
nerves leave the inferior hypogastric plexus to pierce the rectal fascia and enter the rectal wall (rectal pedicle, T-junction).
The remaining nerves of the inferior hypogastric plexus extend in an anterior direction as neurovascular bundles to supply
the urinary bladder, prostate and seminal vesicles. (Reproduced from Schünke, M. et al., Prometheus Atlas of Anatomy,
Vols. 1 and 2. Stuttgart, Germany, Thieme Publ. 2007/2009, with permission.)

can be quite thick and is also termed the rectosacral
fascia or Waldeyer’s fascia.
The presacral fascia is an important surgical
landmark, as it separates the retrorectal space (sur-
gical plane for a TME procedure) from the presac-
ral space and it is intimately associated with the
hypogastric and pelvic splanchnic nerves that form
the inferior hypogastric plexus. The fascial archi-
tecture displays an inner and outer lamella, giving
the presacral fascia the aspect of a double-layered
sheath. The inner lamella borders the posterior
mesorectum, confining the retrorectal space, and
contains the autonomic nerve plexus. For this rea-
son, it has also been called the hypogastric sheath
or the pre-hypogastric nerve fascia. Further an-
teriorly, the presacral fascia reflects at the level of
the rectal pedicles and extends medially towards
the rectogenital septum to fuse with the prostatic
capsule in the male. The outer lamella extends
between the iliac vessels on both sides and deline-
ates the presacral space. Laterally it is pierced by
pelvic splanchnic nerves that originate from sacral
spinal nerves and follow along the presacral fascia
to join the hypogastric nerves to form the inferior
hypogastric plexus (Figure 2.6).
Rectogenital septum
Between the genital organs (vagina in females, pros-
tate and seminal vesicles in males) and the rectum
extends a fascial structure of considerable density
originally described by Denonvilliers as ‘aponévrose
pubio-rectale’,2 which is now recognized as the rec-
togenital septum. In females the rectovaginal septum
is related to the posterior vaginal wall; in males the
rectoprostatic septum (Denonvilliers’ fascia) covers
the prostate, seminal vesicles and the most distal
segments of the vasa deferens and ureters, separat-
ing them from the anterior rectal wall.

HEBK001-C02_p31-51.indd 39 11/02/13 4:31 PM

 40  Anatomy of the rectum, anal canal and pelvic floor
Although intraoperatively the rectogenital septum
seems to comprise a single layer, subtle macroscopic
dissections and histological studies have described
a posterior sheath being the anterolateral lining of
the mesorectum and an anterior sheath adjacent
to the prostate. The rectoprostatic septum is clearly
identifiable as a fascial structure at the level of the
seminal vesicles and upper half of the prostate, but
it often joins the prostatic capsule at the lower half
of the prostate and the apex, making an unequivo-
cal identification more difficult. The rectogenital
septum continues laterally to the presacral fascia, in
particular to its inner lamella containing the inferior
hypogastric nerve plexus. The rectogenital septum
is composed of condensed connective tissue and
smooth muscle cells and is generally well developed.
It is subject, however, to morphological alterations
(e.g. weakening, thinning) with increasing age or dis-
eases of adjacent organs (e.g. rectocele or enterocele
in females, benign prostatic hyperplasia in males).
Its surgical significance derives from the obser-
vation that multiple nerve branches of the inferior
hypogastric plexus pass lateral to and in front of the
rectogenital septum. These autonomic nerve fibres
approach the seminal vesicles, vasa deferens, distal
ureters and prostate dorsolaterally and comprise the
so-called neurovascular bundles responsible for uri-
nary continence and sexual functions. Consequently,
this bilateral nerve network is at risk during surgical
mobilization of the anterior rectal wall, in particular
if the surgical plane is opened not behind but in front
of the rectoprostatic septum with direct exposure of
the seminal vesicles and prostate.
Retrorectal space
The retrorectal space can be considered as a fascial in-
terface extending between the rectal fascia (posterior
mesorectum) anteriorly and the presacral fascia poste-
riorly. This distensible space corresponds to the prop-
er plane for dorsal mobilization of the rectum which
can be achieved by means of gentle traction and coun-
ter-traction. Opening of the retrorectal space reveals
loose areolar connective tissue, which has also been
described quite illustratively as ‘angel’s hair’ (‘cheveux
des anges’) due to its delicate web-like appearance.
As the retrorectal space corresponds to an avas-
cular and nerve-free area, careful dissection will not
result in major bleeding or nerve injury. Occasion-
ally blood vessels originating from the presacral ve-
nous plexus pass through the fascial interface. When
­approaching the pelvic floor, the retrorectal space
HEBK001-C02_p31-51.indd 40
narrows and ends at the level of the fourth sacral ver-
tebra, where the rectal fascia fuses with the presacral
fascia (rectosacral fascia).
Presacral space
The presacral space extends between the presac-
ral fascia and the concave periosteal surface of the
sacrum. This space is by no means an avascular or
nerve-free area, as it contains the medial and lateral
sacral arteries, the presacral venous plexus and the
parasympathetic pelvic splanchnic nerves originat-
ing from the third and fourth sacral nerves. Thus,
the presacral space corresponds to a ‘forbidden
plane’ during the TME procedure, as surgical dis-
section may lead to nerve injury and, in particular,
troublesome venous bleeding. When starting dorsal
mobilization of the rectum, it is essential to clearly
identify the proper plane for TME and not to mis-
take the presacral space for the retrorectal space.
Blood Supply of the Rectum and
Anal Canal
As the rectum derives from the hindgut, the rectum,
including the upper anal canal, is supplied mainly
by the inferior mesenteric artery via the superior
rectal artery (Figure 2.7). The middle and inferior
rectal arteries originate from the internal iliac ves-
sels and contribute to the blood supply of the lower
anal canal and minor parts of the rectum via intra-
mural anastomoses. Occasionally, the posterior part
of the anal canal and internal anal sphincter are ad-
ditionally supplied by the median sacral artery.
Superior rectal artery
The superior rectal artery corresponds to the direct
continuation of the inferior mesenteric artery af-
ter the sigmoid arteries have diverged to supply the
sigmoid mesocolon. The superior rectal artery is of
considerable size (diameter 3.0 6 1.1 mm) and con-
tributes more than 80 per cent to the entire rectal
blood supply. It approaches the dorsal aspect of the
rectal wall by entering the perirectal tissue completely
wrapped by the mesorectal fascia. On its course within
the perirectal tissue, the main trunk generally divides
into three branches that surround the posterolateral
wall of the rectum. The branches ramify further, en-
ter the rectal muscle layers and the submucosa, and
descend towards the upper segment of the anal canal.
Terminal branches supply the haemorrhoidal plexus
11/02/13 4:31 PM

inferior mesenteric
artery median sacral
artery
superior rectal
artery
internal iliac
artery
internal pudend
artery
middle rectal
artery
inferior rectal
artery
Figure 2.7. Arteries of the rectum and anal canal, dorsal
view. The rectal wall, including the upper anal canal, is
supplied mainly by the superior rectal artery derived from
the inferior mesenteric artery. The middle and inferior
rectal arteries originate from the internal iliac vessels and
contribute to the blood supply of the lower anal canal.
(Reproduced from Schünke, M. et al., Prometheus Atlas of
Anatomy, Vols. 1 and 2. Stuttgart, Germany, Thieme Publ.
2007/2009, with permission.)
(corpus cavernosum recti), creating haemorrhoidal
cushions at predilected areas (3, 7 and 11 o’clock with
the patient in the lithotomy position).
Middle rectal arteries
The middle rectal arteries originate from the in-
ternal iliac arteries mostly as direct branches. They
pass above the pelvic floor muscles and approach
the inferior rectum via the rectal pedicles. Thus, the
middle rectal arteries intermingle with rectal nerve
fibres that originate from the inferior hypogastric
plexus and also run within the rectal pedicles (T-
junction). In contrast to the superior rectal artery,
however, the middle rectal arteries are much smaller
in size and inconstantly developed and are present
bilaterally in only about 10 per cent of individuals.
Inferior rectal arteries
The lower anal canal and the anal sphincter complex
are supplied by anal arteries from the inferior rectal
arteries. They diverge from the internal pudendal ar-
teries located within the Alcock canal and approach
the anal region via the ischioanal space, dividing into
ventral and dorsal branches. Functional intramural
anastomoses are established between the inferior,
middle and superior rectal arteries. These multiple
HEBK001-C02_p31-51.indd 41
RECTUM AND ANAL CANAL  41
sources of rectal blood supply are essential for effec-
tive wound healing of deep rectal anastomosis after
removal of the rectum and its major blood supply,
the superior rectal artery.
Lymphatic Drainage of the
Rectum and Anal Canal
Analogous to the blood supply, the lymphatic drain-
age from the rectum is mainly in a cranial direction
and to visceral lymph nodes. Intramural lymphatic
vessels project to perirectal lymph nodes located
within the fatty perirectal tissue, which is completely
enveloped by the mesorectal fascia. Lymphatic col-
lection and drainage occur unidirectionally towards
the major lymph node stations along the superior
rectal and the inferior mesenteric blood vessels.
Depending on the degree of individual develop-
ment of the lymphatic vessels, lymphatic drainage
may also take place via the rectal pedicles towards
the internal iliac lymph nodes. In rectal cancer, this
route of lymphatic spread is generally confined to
advanced tumour stages in which the rectal fas-
cia has been penetrated towards the lateral pelvic
wall. The lower anal canal and the perianal region
are not hindgut derivates and therefore receive a
somatic rather than a visceral lymphatic drainage.
Lymphatic vessels project mainly to inguinal and
external iliac lymph nodes.
Nerve Supply of the Rectum and
Anal Canal
Like the other segments of the gastrointestinal tract,
the distal end comprising the rectal ampulla and up-
per anal canal, including the internal anal sphincter, is
controlled by the autonomic nervous system. In con-
trast, the somatic nerve supply is confined to the stri-
ated musculature of the external anal sphincter and to
the lower anal canal up to the dentate line (Figure 2.8).
Inside the rectal wall resides the enteric nervous
system, which extends throughout the muscular,
submucosal and mucosal layers by forming intramu-
ral nerve plexi. The myenteric and submucosal plexi
are composed of ganglia and interconnecting nerve
fibre bundles, which regulate most of the intestinal
functions (e.g. motility, perception, secretion, ab-
sorption, immune functions). The enteric nervous
system is linked to the central nervous system by
spinal visceral afferents and both sympathetic and
parasympathetic nerve fibres and ganglia.
11/02/13 4:31 PM
 42  Anatomy of the rectum, anal canal and pelvic floor

superior
hypogastric plexus

hypogastric
S1 nerve

S2
inferior
S3
hypogastric plexus
S4
pelvic splanchnic
nerves
levator nerves

pudendal nerve rectal plexus

rectal wall

external anal
sphincter
internal anal
sphincter

Figure 2.8. Somatic nerve supply of pelvic floor muscles (left side) and autonomic nerve supply of the anorectum (right
side), schematic drawing. Somatic nerves derive from sacral spinal nerves (S2–4), release direct nerve branches (levator
nerves) to the levator ani muscle, and form the pudendal nerve to innervate the external anal sphincter and the perineal
region. Autonomic nerves are composed of lumbar sympathetic nerves (superior hypogastric plexus, hypogastric nerves)
and parasympathetic nerves (pelvic splanchnic nerves), which fuse in the inferior hypogastric plexus responsible for the
nerve supply of anorectum, including the internal anal sphincter. (Reproduced from Schünke, M. et al., Prometheus Atlas
of Anatomy, Vols. 1 and 2. Stuttgart, Germany, Thieme Publ. 2007/2009, with permission.)

It is important to emphasize that sympathetic
and parasympathetic nerves supplying the rectum
originate from an extensive nervous network that
is also responsible for the control of urinary con-
tinence and mediation of sexual functions. As the
rectum resides in close proximity to the autonomic
nerve fibre meshes extending towards the urogeni-
tal organs, these nerves are in danger of damage
during surgical removal of the rectal specimen.
Sympathetic nerves support the filling phase of
the urinary bladder under resting conditions by re-
laxing the detrusor vesicae muscle and closing the
internal urethral sphincter, thereby contributing to
urinary continence. For controlled micturition, par-
asympathetic nerves suppress the sympathetic input
and initiate continuous contraction of the detrusor
vesicae muscle. Thus, injury of these nerves may
lead to both urinary incontinence and urinary blad-
der dysfunction, including retrograde ejaculation.
Both sympathetic and parasympathetic nerves are
also involved in regulating sexual functions. Sym-
pathetic nerves mediate ejaculation, and parasym-
pathetic nerves are responsible for the filling of the
cavernous bodies (erection in males, swelling of the
clitoris in females) and for lubrification of the exter-
nal genital organs in both genders. Sexual dysfunc-
tion due to nerve injury is clinically more evident
in male patients, manifesting as sexual impotence
characterized by erectile dysfunction and impaired
ejaculation. The effects and impact of nerve injury
in female patients, such as inability to experience
orgasm and insufficient lubrication, should not be
underestimated, however.
The extent of autonomic nerve injury that results
in definite postoperative impairment of urinary con-
tinence and sexual functions is unclear. In general, the
autonomic innervation of organs is characterized by a
certain functional redundancy, which is anatomically
reflected by a bilateral organization of abundantly
ramifying intrapelvic nerve plexi and collateral nerve
fibres connecting both sides with each other. Thus,
it has been suggested that unilateral damage may
be compensated by the intact contralateral nervous
input, although sexual dysfunction and urinary conti-
nence have also been described after partial damage of
autonomic nerves (Figures 2.9 and 2.10).

HEBK001-C02_p31-51.indd 42 11/02/13 4:31 PM

 RECTUM AND ANAL CANAL  43

Figure 2.9. Autonomic and somatic

nerves of the pelvis, sagittal section of
male pelvis, left view. The hypogastric
nerves diverge from the superior
hypogastric plexus and extend
laterally to the rectum into the inferior
hypogastric plexus, which is joined by
superior
the pelvic splanchnic nerves. Rectal
hypogastric plexus
nerves leave the inferior hypogastric
plexus to enter the rectal wall (rectal hypogastric
plexus), while the remaining nerve nerve
fibres extend further anteriorly as
neurovascular bundles towards the pelvic splanchnic
urinary bladder, prostate and seminal nerves
vesicles. The neurovascular bundles
include the cavernous nerves, which inferior
enter the cavernous bodies. The hypogastric plexus
pudendal nerve extends below the neurovascular rectal plexus
levator ani muscle and provides the bundles pudendal nerve
somatic nerve supply of the striated cavernous nerves
levator ani muscle
pelvic floor muscles and the skin of
perineal nerves
the perineal region and external genital
dorsal penile nerve inferior rectal nerves
organs. (Reproduced from Schünke,
M. et al., Prometheus Atlas of Anatomy, external anal
Vols. 1 and 2. Stuttgart, Germany, sphincter
Thieme Publ. 2007/2009, with
permission.)

Figure 2.10. Perirectal

spaces, dissected superior hypogastric
pelvis, cranial view. plexus
superior rectal
The rectum is retracted
artery
together with the rectal
fascia to illustrate the
retrorectal space and presacral space
the presacral space with presacral vessels
(forceps inserted). Note
that the presacral fascia
hypogastric
is removed to expose nerve
the autonomic nerves
(superior hypogastric
plexus, hypogastric
inferior
nerves) embedded rectal hypogastric plexus
within this fascia. From fascia
the inferior hypogastric
plexus diverge nerve
fibres via the rectal T-junction
pedicles (T-junction) into
the rectal wall.

HEBK001-C02_p31-51.indd 43 11/02/13 4:32 PM

 44  Anatomy of the rectum, anal canal and pelvic floor
Sympathetic nerves
Lumbar sympathetic nerves pass along and in front
of the descending aorta and form fairly well-defined
periarterial nervous networks, the inferior mesenter-
ic and superior hypogastric plexus. These networks
enclose the inferior mesenteric artery up to 5 cm
from its origin from the aorta. A high-tie arterial li-
gation is virtually impossible without damaging, at
least in part, adjacent sympathetic nerve fibres. Thus,
when disconnection of the rectal blood supply is car-
ried out, a low-tie ligation of the inferior mesenteric
artery is generally preferred to avoid impairment of
both urinary continence and sexual functions at this
initial surgical step.
When the superior hypogastric plexus has en-
tered the pelvic cavity in front of the promonto-
rium, it divides into the left and right hypogas-
tric nerve. The hypogastric nerve does not always
present as a single clearly defined nerve; often it
consists of different nerve fibre bundles arranged
in parallel oriented intermingling strings. Both
hypogastric nerves are attached to the inner lamella
of the presacral fascia corresponding to the parietal
pelvic fascia extending in front of the sacral con-
cavity. Due to the intimate relationship between
the hypogastric nerves and the presacral fascia, this
fascial layer has also been termed the hypogastric
sheath or the pre-hypogastric nerve fascia. Gentle
traction on the hypogastric nerves will lift this fas-
cial sheath, helping to visualize the course of the
nerves down to the inferior hypogastric plexus.
Parasympathetic nerves
Parasympathetic nerves derive from the sacral por-
tion of the parasympathetic nervous system located
within the sacral spinal cord. Together with thick
ventral branches of the sacral spinal nerves (S2–4),
they leave throughout the ventral sacral foramina
as so-called pelvic splanchnic nerves. Due to one
of their main functions, they are also termed eri-
gent nerves or erigent pillars. The pelvic splanch-
nic nerves pierce the presacral fascia at the left and
right sides and follow this fascial plane to join the
inferior hypogastric plexus, where they intermingle
with their sympathetic counterparts.
Inferior hypogastric plexus/pelvic plexus
The inferior hypogastric plexus, also termed the
pelvic plexus, is an extensive network of autonomic
nerve fibres composed of sympathetic nerves origi-
HEBK001-C02_p31-51.indd 44
nating from the left and right hypogastric nerves
and parasympathetic nerves originating from pel-
vic splanchnic nerves (Figure 2.11). The inferior
hypogastric plexus is embedded in connective tissue
of the parietal pelvic fascia. At the level of the rec-
tal pedicles, small branches diverge from the main
nerve plexus and enter the rectal wall (T-junction).
The inferior hypogastric plexus extends further in
an anterior direction as a fan-like network radiat-
ing cranially as high as the seminal vesicles, distal
ureters and vasa deferens and caudally towards the
apex of the prostate and the upper aspect of the
perineal body (Figure 2.12).
The lower part of the inferior hypogastric plexus
has been described by Walsh and colleagues as neu-
rovascular bundles extending dorsolaterally along
the prostate to approach the apex of the prostate
and penetrate the urogenital diaphragm.3 The neu-
rovascular bundles contain the cavernous nerves re-
sponsible for erectile functions and terminal nerve
fibres innervating the internal urethral sphincter.
Thus, special attention should be given to this lower
portion of the inferior hypogastric plexus, as these
nerve fibres are closely related to the anterior rectal
wall, before they continue along the transverse peri-
neal muscles into the penile bulb. The same holds
true in female patients in whom the lowermost por-
tion of the inferior hypogastric plexus runs along
the lower lateral wall of the vagina.
The upper part of the inferior hypogastric plexus
extending along the prostate and seminal vesicles
is separated from the rectum by the rectoprostatic
septum (Denonvilliers’ fascia) (Figure 2.13). As long
as the anterior surgical dissection plane is behind
the rectoprostatic septum, preservation of these
nerves is feasible. Some communicating nerve fibres
between the left and right inferior hypogastric plexus
pass and cross in front of the rectoprostatic septum.
This exchange of nerve fibres may explain why uni-
lateral lesions of the inferior hypogastric plexus may
be compensated by the intact contralateral plexus.
Despite the presence of autonomic nerve fibres at
the midline, this area is still the favoured approach to
initiate anterior mobilization of the rectum, because
nerve fibre density constantly increases towards the
lateral sides of the rectoprostatic septum.
Somatic nerves
The autonomic nerve supply of the rectum and anal
canal ends at the level of the dentate line. Below this
11/02/13 4:32 PM
 RECTUM AND ANAL CANAL  45

superior hypogastric
plexus
hypogastric
nerve

pelvic splanchnic
nerves vas deferens
Figure 2.11. Dissected left male
hemipelvis with pelvic organs,
right anterior view. The levator ani
urinary bladder
muscle is pulled back to expose the
course of the autonomic nerves. inferior seminal vesicle
The hypogastric nerve diverges hypogastric plexus
from the superior hypogastric
plexus and extends laterally to the rectal plexus
prostate
rectum into the inferior hypogastric
plexus, which is joined by the pelvic
cavernous nerves
splanchnic nerves. Rectal nerves levator nerves
leave the inferior hypogastric plexus rectum
to enter the rectal wall, while the penile bulb
levator ani
remaining nerve fibres extend
muscle urethra
further anteriorly as neurovascular
bundles towards the urinary
bladder, seminal vesicles, prostate
and cavernous bodies.

embryologically defined border between the gas-
trointestinal tract (‘visceral individuum’) and the
pelvic floor, including the perineal region and the
external anal sphincter (‘somatic individuum’), so-
matic nerves are in charge for both sensory and mo-
tor functions. The lower anal canal comprising the
anoderm and perianal region is supplied by perianal
branches of the pudendal nerves. In contrast to the
autonomically innervated rectum, the anodermal
segment is highly sensitive to touch, pressure, pain

Figure 2.12. Dissected right male

hemipelvis with pelvic organs partly ureter
reflected, left view. The entire rectum
together with the intact mesorectum urinary bladder
is mobilized and pulled out of the seminal vesicle
pelvic cavity, attached only to hypogastric
the perineal body anteriorly. This prostate nerve
procedure allows optimal exposure
of the right hypogastric nerve, pelvic parietal pelvic fascia
splanchnic nerves and the extensive
nervous network of the inferior inferior
hypogastric plexus
hypogastric plexus (green strips). neurovascular
Nerve fibres of the inferior hypogastric bundle
plexus extend towards the ureter, perineal body pelvic splanchnic
seminal vesicle (yellow strip), urinary nerves
bladder and prostate, and down to
anterior
the cavernous bodies (red vessel
mesorectum
loop) as neurovascular bundles.

HEBK001-C02_p31-51.indd 45 11/02/13 6:38 PM

 46  Anatomy of the rectum, anal canal and pelvic floor

urinary bladder
peritoneum

Figure 2.13. Dissected

right male hemipelvis
seminal vesicle with pelvic organs, left
view. The rectoprostatic
neurovascular
septum (Denonvilliers’
bundle
fascia) is grasped by
prostate the right forceps and
retracted dorsally
together with the
anterior rectal wall.
rectoprostatic septum
The left forceps
(Denonvillier´s fasica)
grasps the posterior
anterior wall of the urinary
rectal wall bladder. Between the
rectoprostatic septum
anal and the prostate/
canal
seminal vesicles extend
the neurovascular
bundles.

and temperature, due to densely distributed somato-
sensory nerve endings. The external anal sphincter is
innervated by inferior rectal nerve branches provided
by the pudendal nerves. It is notable that a subgroup
of healthy males and females reveals an asymmetry
of external anal sphincter innervation, with a func-
tional preponderance of either the left or right pu-
dendal nerve.
PELVIC FLOOR
The pelvic floor is composed of both striated and
smooth muscles covered by fasciae and thus corre-
sponds to a rhabdo- and lissomusculofibrous system.
The pelvic floor has a twofold function: closure of the
pelvic cavity for the support of intrapelvic organs,
and controlled opening for micturition and defeca-
tion in both genders and parturition in females. The
female pelvic floor is larger than the male, displaying
wider urogenital openings, but its muscle strength
is generally lower and the nerve supply is less devel-
oped. The female pelvic floor is therefore capable of
allowing vaginal delivery on the one hand, but on the
other hand it is more susceptible to functional insuf-
ficiency and pelvic organ prolapse.
The pelvic floor can be subdivided into a pelvic
diaphragm, which is composed mainly of the levator
ani muscle and a urogenital diaphragm comprising
the transverse perineal muscles. In addition to these
major striated muscles composed mainly of slow-
twitch type I fibres, the pelvic floor is also equipped
with smooth musculature. The smooth muscle
components are located predominantly along the
border of the urogenital and anal hiatus created by
the levator ani muscle. Further smooth muscle fi-
bres have also been described extending from the
rectal wall to the vagina (rectovaginal muscle) to the
urethra (recto-urethral muscle) and to the coccyx
along the anococcygeal ligament (rectococcygeal
muscle, retractor recti muscle or Treitz muscle).
Pelvic Diaphragm/Levator Ani Muscle
The largest of the pelvic floor muscles is the levator
ani muscle, and the term ‘levator ani’ is often used to
mean the entire pelvic floor. In fact, the levator ani
muscle covers most of the lower pelvic aperture and
leaves only a midline gap for the urethra and vagina
(urogenital hiatus) and the anal canal (anal hiatus)
(Figure 2.14). This anterior slit-like opening is partly
closed by the urogenital diaphragm at the level of
the urogenital hiatus. The levator ani muscle corre-
sponds to a broad, flattened, funnel-shaped muscle
that originates from the pelvic wall. The muscular

HEBK001-C02_p31-51.indd 46 11/02/13 4:32 PM


urogenital
hiatus puborectal
internal obturator muscle
muscle pubococcygeal
tendinous arc muscle
ileococcygeal
muscle
anal coccygeal
hiatus muscle
piriformis
muscle
Figure 2.14. Pelvic floor, cranial view. The pelvic
diaphragm is formed by the levator ani muscle composed
of the puborectal muscle, pubococcygeal muscles and
ileococcygeal muscles. Most of the levator ani muscle
originates from the tendinous arc (‘white line’), which
corresponds to a condensed connective tissue line of
the obturator fascia. The puborectal sling forms a midline
gap for the urethra and vagina (urogenital hiatus) and the
anal canal (anal hiatus). The coccygeal muscles extend
from the ischiadic spine to the lateral margins of the
coccyx following the course of the sacrospinal ligaments.
(Reproduced from Schünke, M. et al., Prometheus Atlas
of Anatomy, Vols. 1 and 2. Stuttgart, Germany, Thieme
Publ. 2007/2009, with permission.)
funnel descends towards the anus and fuses with the
external anal sphincter. The levator ani muscle is
composed of the following parts:
Ileococcygeal muscles
The ileococcygeal muscles make up the largest por-
tion of the levator ani muscle and originate from
the tendinous arc (arcus tendineus fasciae pelvis)
formed by a condensed tissue line (‘white line’) of
the obturator fascia. Thus, its muscular insertion
sides are not rigid but correspond to a dynamic sus-
pension, allowing a degree of compliance against
traction and pressure forces. The flattened muscles
attach to the coccyx and the last two sacral vertebrae
and fuse posteriorly in a midline raphe. The funnel-
shaped muscle is generally very thin and displays
intramuscular slit-like gaps, particularly in females.
Pubococcygeal muscle
In contrast to the non-bony origin of the ileococcy-
geal muscles, the pubococcygeal muscle runs from
the inner surface of the pubic bone to the coccygeal
HEBK001-C02_p31-51.indd 47
PELVIC FLOOR  47
bone, where it is attached by a tendinous plate. The
pubococcygeal muscle adapts the shape of a ham-
mock extending above the ileococcygeal muscles.
Some muscle fibres decussate to the periurethral
musculature and insert into the walls of the vagina
(pubovaginal muscle) and rectum and anal canal
(puboanal muscle). The puboanal fibres blend with
fibres of the longitudinal rectal muscle to form the
conjoint longitudinal muscle.
Puborectal muscle
The puborectal muscle is inseparable from the pub-
ococcygeal muscle at its origin at the pubic bone, but
more posteriorly the muscle angles at the anorectal
junction to form a sling behind the rectum. Con-
traction will compress the anal canal by pulling
the anorectal junction towards its fixed point (the
pubic bone), thereby reducing the anorectal angle.
The puborectal sling is intimately fused with the
deep part of the external anal sphincter. From the
caudal part of the muscle, pre-rectal fibres decus-
sate to insert into the perineal tendinous centre.
The puborectal muscle delimits the levator ani gap
bordering the urogenital and anal hiatus.
Coccygeal muscles
The coccygeal muscles are located dorsocranially to
the levator ani muscle and extend from the ischial
spine to the lateral margins of the coccyx. The mus-
cle tissue is generally poorly developed and follows
the course of the sacrospinal ligaments. Lying in the
same plane as the levator ani muscle, the coccygeal
muscles complete the pelvic diaphragm at its dor-
socranial end.
Urogenital Diaphragm
The midline gap left by the levator ani muscle for
the urogenital hiatus is covered by the urogenital
diaphragm. This diaphragm extends between both
inferior branches of the pubic bone and corre-
sponds to a musculofibrous plate. In elderly people,
and in particular in females after multiple vaginal
deliveries, the muscular tissue is almost completely
replaced by connective tissue. In the midline, an
anterior opening is left for the urethra surrounded
by the omega-shaped external urethral sphincter.
Posteriorly, the urogenital diaphragm has an open-
ing in females for the vaginal wall.
11/02/13 4:32 PM
 48  Anatomy of the rectum, anal canal and pelvic floor
Deep transverse perineal muscle
Most of the urogenital diaphragm is made up of
the deep transverse perineal muscle. According to
its name, the muscle fibres extend in a transverse
direction between the left and right inferior pubic
branch. The thin muscular plate is interwoven with
connective tissue and widens in a posterior direc-
tion, adopting a triangular shape. The muscular
portion adjacent to the passage of the vaginal tube
is also termed the constrictor vaginae muscle.
Superficial transverse perineal muscle
The dorsal aspect of the deep transverse perineal
muscle is bordered by the superficial transverse
perineal muscle. The slender muscle also extends
between the inferior pubic branches near the ischial
tubercles and is connected to the perineal tendinous
centre (Figure 2.15).
Nerve Supply of the Pelvic
Floor and Perineal Region
All striated muscles of the pelvic floor are innervat-
ed by nerves diverging from the ventral branches of
the sacral spinal nerves (S2–4). The somatomotor
external urethral
sphincter
deep transverse
perineal muscle
superficial transverse
perineal muscle
internal obturator anal
puborectal
muscle muscle
hiatus
ileococcygeal
muscle
piriformis
muscle coccygeal
muscle
Figure 2.15. Female pelvic floor, caudal view. The
urogenital hiatus of the pelvic diaphragm is covered
caudally by the urogenital diaphragm composed of the
deep and superficial transverse perineal muscles. The
urogenital diaphragm extends between both inferior
branches of the pubic bone and corresponds to a thin
musculofibrous plate. An anterior opening is left for the
urethra surrounded by the external urethral sphincter.
Posteriorly, the urogenital diaphragm gives way for the
vaginal wall. (Reproduced from Schünke, M. et al.,
Prometheus Atlas of Anatomy, Vols. 1 and 2. Stuttgart,
Germany, Thieme Publ. 2007/2009, with permission.)
HEBK001-C02_p31-51.indd 48
input is provided by direct sacral nerves and the pu-
dendal nerves. The pudendal nerves also carry the
somatosensory supply for the perineal region, in-
cluding the highly innervated anodermal segment
of the lower anal canal.
Direct sacral nerves/levator nerves
The direct sacral nerves for the innervation of the
muscular pelvic diaphragm originate from the
third and fourth sacral nerves. The small-sized
nerves, also termed levator nerves, leave the an-
terior sacral foramina and run from the sacral
concavity directly towards the levator ani muscle.
They approach the levator ani muscle from above
and penetrate into its muscle fibres. When reach-
ing the pelvic floor from above during a TME pro-
cedure, care must be taken to preserve these direct
nerve branches.
Pudendal nerves
The pudendal nerves (Figure 2.16) arise from the
second, third and fourth sacral nerves and initial-
ly leave the pelvic cavity together with the sciatic
nerves via the greater sciatic foramen. Once they
have passed through the infra-piriformis gap,
they curve around the sacrospinal ligament at
the level of the ischial spine to re-enter the pelvis
via the lesser sciatic foramen. The re-entry takes
place at the infralevatory level within the ischio-
anal space.
The main pudendal nerve branch is ensheathed
by a duplication of the obturator fascia (Alcock’s
canal) together with accompanying internal pu-
dendal blood vessels. Along its way towards the
pubic bone, multiple branches leave Alcock’s ca-
nal, run throughout the fatty tissue of the ischio-
anal space and reach the entire perineal region
with somatomotor and somatosensory terminal
nerve fibres. Inferior rectal nerves innervate the
external anal sphincter, the lower portion of the
levator ani muscles, and the perianal skin and
anoderm. Further ventrally, perineal nerves ap-
proach the urogenital diaphragm for innervation
of the transverse perineal muscles and the exter-
nal urethral sphincter and for the sensory nerve
supply of the perineal region, including the scro-
tal and labial skin. The dorsal nerve of the penis
and clitoris in males and females, respectively,
travels above the urogenital diaphragm towards
the cavernous bodies.
11/02/13 4:32 PM
 PELVIC FLOOR  49

sacrotuberal levator ani

ligament muscle

pudendal anococcygeal
nerve branches ligament
fascia of internal
Figure 2.16. Female pelvic floor with obturator muscle
dissection of the left perineal region,
dorsocaudal view. The fascia (grasped inferior rectal
by forceps) of the internal obturator ischiadic nerves
muscle is incised and opened to release tubercle external anal
the pudendal nerve fibres from Alcock’s sphincter
canal and to illustrate its terminal
anus
branches (green vessel loop). Inferior
perineal
rectal nerves run towards the external
nerves
anal sphincter and perianal region.
Perineal nerves extend in an anterior vaginal
direction to innervate the urogenital introitus
diaphragm and the vaginal introitus.

The terminal branches of the pudendal nerves The ventral part of the ischioanal fossa is caudally
are located at the outer surface of the puborectal closed by the urogenital diaphragm. The dorsal part
muscle and come into close proximity with the surrounds the lower anal canal and widens towards
neurovascular bundles at the level of the pro- the sacrotuberal ligaments and the gluteus maximus
static apex. At this point, fine branches of the
pudendal nerves intermingle with nerve fibres
from the neurovascular bundles to innervate the
urinary sphincter complex. This region is located
near the anterior dissection plane, and caution
should be taken to preserve these nerves, in par-
ticular if surgical resection is extended down to tendinous
the pelvic floor in abdominoperineal excision of arc
internal obturator
the rectum. muscle ischioanal
space

Ischioanal Space
Below the pelvic diaphragm extends the ischioanal
space, or fossa, which corresponds to the infradia-
phragmatic or infralevatory pelvic compartment
extending below the pelvic floor. In a frontal cross-
sectional plane, the ischioanal space appears as a
triangle with its base oriented towards the perineal
skin, the lateral side limited by the internal obtu-
rator muscle, and the medial side bordered by the
funnel-shaped levator ani muscle (Figure 2.17).
The apex represents the junction of both muscles
along the tendinous arc. At the lateral side-wall ex-
tends Alcock’s canal, a duplication of the internal
obturator fascia harbouring the main branches of
the internal pudendal vessels and pudendal nerves.
superficial perineal
Alcock´s canal with fascia
pudendal vessels & nerve
superficial perineal/
external anal perianal space
sphincter internal anal
sphincter
Figure 2.17. Rectum, anal canal and pelvic floor, frontal
section, anterior view. The levator ani muscle originates
at the tendinous arc on both sides and forms the funnel-
shaped pelvic diaphragm extending down to the external
anal sphincter. The triangular space delimited by the
levator ani muscle, the internal obturator muscle and the
superficial perineal fascia corresponds to the ischioanal
space. The main pudendal nerve branch and internal
pudendal blood vessels are ensheathed by a duplication
of the obturator fascia (Alcock’s canal). (Reproduced from
Schünke, M. et al., Prometheus Atlas of Anatomy, Vols. 1
and 2. Stuttgart, Germany, Thieme Publ. 2007/2009, with
permission.)

HEBK001-C02_p31-51.indd 49 11/02/13 6:38 PM

 50  Anatomy of the rectum, anal canal and pelvic floor
muscles. The ischioanal fossa is filled with loosely
arranged areolar fat (corpus adiposum perinei) and
contains the terminal branches of the pudendal
nerves and blood vessels. Posteriorly, the ischioanal
space is crossed in the midline by the anococcygeal
ligament extending from the external anal sphinc-
ter to the coccygeal bone.
At the perianal region, the ischioanal space is
caudally delimited by a thin fascia, the superficial
perineal fascia, formed by diverging tendinous end-
ings of the conjoint longitudinal muscle. Below this
connective tissue plane extends the perianal space.
This space corresponds to the subcutaneous layer
underlying the perianal skin and contains small fat
lobules separated by rigid connective tissue septa.
The ischioanal space is particularly important in
abdominoperineal excision for low rectal cancer. In
conventional abdominoperineal excision, a classi-
cal TME is performed and the ischioanal space is
dissected only up to the external anal sphincter by
the perineal approach. This procedure often bears
the risk of a ‘tissue waist’ at the tumour site and
thus is associated with increased rates of positive
circumferential resection margins and inadvertent
bowel perforation. The modified surgical proce-
dure, also described as ‘cylindrical abdominoperi-
neal excision’, consists of an extended extralevator
­abdominoperineal ­excision (ELAPE). The ELAPE
procedure avoids the tissue waist at the anorectal
junction by stopping the TME above the pelvic
floor and by extending the perineal dissection up to
the origin of the levator ani muscle. For this reason,
the ischioanal space has to be dissected along the
outer surface of the external anal sphincter and of
the funnel-shaped levator ani muscle until reach-
ing its origin at the tendinous arc. Subsequently,
the resulting specimen will include the entire anal
sphincter complex together with major parts of
the levator ani muscle completely enveloping the
tumour-bearing region.
Perineal Body/Perineal
Tendinous Centre
The perineal body corresponds to the centre of the
perineal region that serves as a common insertion
site for several muscles of the pelvic floor and there-
fore is also termed the perineal tendinous ­centre.
Attached to the perineal body are the superficial
HEBK001-C02_p31-51.indd 50
transverse perineal muscle and bulbospongious
muscle in front, the superficial portion of the ex-
ternal anal sphincter at the back, and transversely
running fibres of the puborectal muscle from the
lateral sides.
The perineal body serves as an anterior abutment
for the anorectal junction. It is virtually impossi-
ble to define a clear surgical dissection plane in this
area, because longitudinal smooth muscle bundles
deriving from the anterior rectal wall (corrugator
ani muscle) and the inferior continuation of the
rectogenital septum are intimately connected to the
perineal body. Moreover, both the urogenital dia-
phragm and the external anal sphincter are firmly
attached to the perineal body. In males, fibres of the
bulbospongious muscle regularly cross the perineal
body and fuse with fibres of the superficial portion
of the external anal sphincter. The condensation of
smooth muscle fibres that connect the anorectal
junction to the perineal body and thence to the ure-
thra is also called the recto-urethralis muscle.
In abdominoperineal excision, detachment of
the anterior aspect of the anorectal specimen ap-
pears to be one of the most delicate steps, since this
region lacks self-opening planes. Thus, dissection
has to be carefully carried out behind the superficial
transverse perineal muscle to avoid perforation of
the bowel wall and damage of the urethral sphincter
complex and its corresponding nerves.
Acknowledgements
The author wishes to thank Dr Sigmar Stelzner
(Department of General and Visceral Surgery,
Dresden-Friedrichstadt General Hospital, Germany)
for his valuable contributions regarding the anatomi-
cal dissections, and Günter-Rudolf Klaws and Stefanie
Gundlach (Institute of Anatomy, Christian Albrechts
University of Kiel, Germany) for their assistance in
the anatomical dissections and photographing.
References
1. Stelzner F. Chirurgie an den viszeralen Abschlusssyte-
men. Stuttgart, Thieme, 1998.
2. Valleix MM et al. Bulletin Nr. 10, third série. Juin 1836.
3. Walsh PC, Lepor H, Eggleston JC. Radical prostatecto-
my with preservation of sexual function: anatomical and
pathological considerations. Prostate 1983; 4: 473–85.
11/02/13 4:32 PM
 FURTHER READING  51

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H. The rectogenital septum: morphology, function, and
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clinical relevance. Dis Colon Rectum 2004; 47: 131–40.
Kirkham AP, Mundy AR, Heald RJ, Scholefield JH. Cadav-
Baader B, Herrmann M. Topography of the pelvic autonomic
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nervous system and its potential impact on surgical
Engl 2001; 83: 89–95.
intervention in the pelvis. Clin Anat 2003; 16: 119–30.
Kourambas J, Angus DG, Hosking P, Chou ST. A histologi-
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Clausen N, Wolloscheck T, Konerding MA. How to optimize
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Lindsey I, Warren BF, Mortensen NJ. Denonvilliers’ fascia
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excision for rectal cancer. Br J Surg 1996; 83: 384–8.
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of approach in abdominoperineal resection. J Clin
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Oncol 2005; 23: 9257–64.
function after total mesorectal excision with autonomic
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nerve preservation for carcinoma of the rectum. J Am
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49: 1024–32.

HEBK001-C02_p31-51.indd 51 11/02/13 4:32 PM


Oliver Shihab and Arcot K. Venkatasubramaniam
Introduction
Accurate preoperative staging of rectal cancer influ-
ences the choice of surgery and the use of neoad-
juvant therapies, with the aim of achieving a clear
resection margin. It is also possible that, in selected
early tumours, resectional surgery may be avoided
with the use of local excision. The endorectal ultra-
sound (EUS) staging system, its accuracy with
respect to other imaging modalities, and the clini-
cal role of EUS in the assessment of rectal cancer are
discussed in this chapter.
Imaging technique
Endorectal ultrasound is the oldest imaging modal-
ity for local staging of rectal cancer1 and can be
conveniently performed in the office setting by the
colorectal surgeon. Endorectal ultrasound typically
uses a rigid probe with a rotating ultrasound trans-
ducer mounted at the tip. This ultrasound trans-
ducer contains crystals that emit sound waves when
electrically stimulated, producing images orthogo-
nal to the probe (Figure 3.1). A balloon filled with
degassed water is at the tip of the probe, passing the
emitted sound waves to the rectum via the water,
so preventing image distortion by air. The depth of
penetration of these waves is a function of the focal
length of the crystals: those that produce higher-
frequency waves produce a higher-resolution image
HEBK001-C03_p52-57.indd 52
3
Clinical ultrasound
but give a poorer depth of penetration.2 In EUS,
frequencies of 7.0 MHz or 10 MHz are most com-
monly used and give satisfactory images.
STAGING
Primary Tumour Staging
Using EUS, it is possible to clearly visualize five
ultrasonic layers of the rectum and surround tis-
sues, which correspond to the five anatomical lay-
ers. The EUS appearances alternate between echo-
genic and echo-poor:3
l mucosa (echogenic);
l muscularis mucosae (echo-poor);
l submucosa (echogenic);
l muscularis propria (echo-poor);
l serosa/perirectal fat (echogenic).
The traditional staging system using EUS fol-
lows the method of Hildebrandt and Feifel:4 They
established the use of the TNM (tumour, node,
metastasis)-based system for EUS, with the ‘u’ pre-
fix to show that the staging had been predicted by
ultrasound, using the relationship of the hypoecho-
ic tumour to ultrasonic layers, as described above:
l uT0: tumour confined to the mucosa only.
l uT1: tumour confined to the mucosa and sub-
mucosa.
08/02/13 6:41 PM

Figure 3.1. Anorectal transducer (courtesy BK medical). Scanning plane for the anorectal transducer.
l uT2: tumour invades muscularis propria but is
confined to the rectal wall.
l uT3: tumour invades perirectal tissues but does
not involve adjacent organs.
l uT4: tumour invades adjacent organs.
Accuracy for depth of invasion is high, with stud-
ies showing this to be in the region of 74–96 per
cent.5–13 In one study, however, after neoadjuvant
radiotherapy the T-stage accuracy of EUS fell from
86 per cent in the non-irradiated patient cohort
to 47 per cent in the irradiated cohort. It was sug-
gested that irradiation and subsequent rectal wall
thickening resulted in poor visualization of the rec-
tal wall layers.14 Another study demonstrated that
EUS correctly predicts cases of complete response
following neoadjuvant therapy in 63 per cent of
patients and correctly predicts T stage in 48 per cent
of patients.15
In earlier cancers (SM1-T2), overall accuracy
of EUS is particularly high, in the region of 92 per
cent.9,16 This compares favourably with magnetic
resonance imaging (MRI), which has an accuracy
of 67–86 per cent.17–19 The lower accuracy seen with
MRI is thought to be due to the poor differentiation
of T1/2 cancer from very early T3 cancer, where
it can be difficult to distinguish true mesorectal
tumour invasion from desmoplastic reactions. Use
of a 15 MHz probe (resulting in an increased resolu-
tion but decreased focal length) has a high accuracy
(86 per cent) in distinguishing the earliest lesions
HEBK001-C03_p52-57.indd 53
STAGING  53
of the submucosa (SM1) from those with greater
depth of invasion.20 This is of clinical importance,
because patients with SM1 or lower disease have
an extremely low risk of lymph node metastasis.9,21
Accurate identification of this subgroup could
therefore allow for safe local excision of the cancer.
Lymph Node Staging
Prediction of lymph node involvement is prob-
lematic, because approximately half of all lymph
nodes with metastatic spread are less than 5 mm in
diameter22 and up to 18 per cent of lymph nodes
of 4 mm or less may contain tumour metastases.23
Although there is an association with lymph node
size and likelihood of tumour metastasis, there is
considerable overlap in size between metastatic
and non-metastatic nodes. As such, lymph node
involvement lacks sufficient discrimination to be
used as a staging criterion. It has been noted, how-
ever, that for grossly enlarged mesorectal nodes
(.9 mm in short-axis diameter), there is almost
invariably involvement by tumour.24 Other criteria
used in staging include inhomogeneity, long-axis
to short-axis diameter ratio (‘roundness index’),
echogenicity, lymph node hilar reflectivity and
border contour.23–26
A small number of studies have examined the
role of fine-needle aspiration (FNA) cytology in
08/02/13 6:41 PM
 54  Clinical ultrasound
improving the accuracy of nodal staging.27,28 Typi-
cally this uses a longitudinally oriented ultrasound
probe, enabling the biopsy needle to accurately pass
into the target area. Although this has proven tech-
nically feasible, the role in rectal cancer is yet to be
defined. In the study by Harewood and colleagues,
there was no significant improvement in accuracy
of nodal staging using EUS and FNA, compared
with EUS alone.28 Importantly, with FNA there is
a theoretical risk of disseminating cancer cells into
the surrounding mesorectum.
Nodal disease continues to present a prob-
lem, regardless of the imaging modality used, and
results are still disappointing when compared with
the staging of direct tumour invasion. Accuracy
for EUS has been quoted as varying from 61 per
cent to 83 per cent,6–11 while MRI has an accuracy
of 57–85 per cent.17,19 Hilar reflectivity and lymph
node inhomogeneity appear to have the greatest
discriminatory value for prediction of lymph node
involvement.24
The Low Rectum and Anal Canal
In the lower third of the rectum (below the origin
of the levator muscles and usually within 6 cm of
the anal verge), the mesorectum tapers sharply and
no longer forms a protective barrier against tumour
spread. The anal canal is generally considered to
extend from the upper border of puborectalis to
the anal verge and is formed by the circular muscles
of the internal and external anal sphincters, which
form a partially overlapping tube of muscle.
At the level of the sphincters the distinction
between T2 tumours (invading muscularis propria,
which, at this level, is the internal anal sphincter),
T3 tumours (through the internal sphincter into
the intersphincteric space) and T4 tumours (invad-
ing the external sphincter) is very small and diffi-
cult to determine with any degree of certainty. The
depth of tumour invasion at this level has important
implications in optimal preoperative and operative
management, particularly the aspects of sphincter
salvage or removal.
Many centres give neoadjuvant chemoradio-
therapy based on the height of tumours, due to
the greater rate of margin involvement at surgery.
Careful anatomical staging allows refinement of
this. The benefits of neoadjuvant therapy have to
HEBK001-C03_p52-57.indd 54
be balanced against the immediate and long-term
complications, such as perineal wound break-
down in abdominoperineal excision (APE)29 and
well-documented long-term effects, including
pelvic fractures, increased risk of second primary
tumours and alterations in urinary, bowel and sex-
ual ­function.30 For these reasons, accurate imaging
at this height is crucial in optimal management and
poses particular challenges in the lowest rectal can-
cers at the level of the sphincters.
Historically, several studies have demonstrated
the ability of EUS to define the anal sphincters
and outline sphincter defects (typically in patients
investigated for faecal incontinence) and to define
­fistulae-in-ano.4,31–34 Furthermore, EUS can pro-
vide reliable measurements of the external anal
­sphincter.35 There have been very few studies, how-
ever, of the ability of EUS to define the extent of
sphincter infiltration by rectal carcinoma. The
one study found is limited by its small number of
patients (n = 12).36 Endorectal ultrasound does,
however, seem promising when compared with
pathology of the excised specimen, with 100 per
cent sensitivity and specificity for pT2 and pT4
tumours and 86 per cent sensitivity and specificity
for pT3 tumours. Furthermore, 5 of the 12 tumours
were post-chemoradiotherapy when assessed by
EUS, and all of these were staged correctly.
There are some reports on the staging accuracy
of EUS in anal squamous cell carcinoma, which also
has the potential to invade the sphincter complex.
As with the rectal cancer studies, published reports
on anal cancer and sphincter invasion are few in
number and have small study sizes.
One study involved 12 patients with anal cancer,
all of whom were staged by EUS;37 of these, only 5
patients underwent surgery, allowing EUS staging
to be compared with histopathology. Two tumours
were classified as uT2a (invading the internal anal
sphincter) and three were classified as uT2b (invad-
ing the external sphincter); histology was in exact
concordance in these cases.
Three-dimensional
endorectal ultrasound
Three-dimensional ultrasound reconstructs radial and
longitudinal images to produce a three-­dimensional
image and may provide a more accurate anatomical
08/02/13 6:41 PM

view of the rectum and surrounding structures. Its
use is said to improve both primary tumour and
nodal staging.26,38,39 This improved accuracy has also
been described in the selection of early tumours for
local excision40 and is also said to produce accurate
information with regard to the down-staging of
tumours following neoadjuvant therapies.41
Limitations of endorectal
ultrasound
Technical aspects of EUS must also be consid-
ered. Problems are similar to those faced with the
endorectal coils in MRI before the introduction of
pelvic phased-array coils. The size of the probe used
is significant, as it has been found that larger probes
result in stretching of the anal canal. This distorts
the anatomy of the region, so potentially affect-
ing the image.42 This anatomical distortion is also
seen with the use of a water-filled balloon, used for
acoustic coupling, in the anal canal.26 It is possible
to overcome this distortion by using a rigid plas-
tic cone in place of the balloon. A tumour that is
stenosing or that has a large polypoid intraluminal
component may also provide a physical barrier to
accurate staging, which occurs in around 5 per cent
of rectal cancers.43 Unlike MRI, where planes can be
planned so that they lie orthogonal to the tumour
and anal canal, it is possible that EUS can produce
images that are oblique to the canal. These oblique
images have the effect of exaggerating the apparent
stage of the tumour.44
Harewood and colleagues hypothesized that
small numbers influenced reported accuracy
of EUS.45 They reported an inverse relationship
between study size and accuracy of EUS and specu-
lated that this could partly result from publication
bias. This may indicate that the accuracy of EUS has
been historically overestimated. This is emphasized
by the decline in the published accuracy of tumour
staging over time.38
The biggest limitation for EUS in the staging of
rectal cancer is that it permits only limited evalua-
tion of the structures surrounding the rectal wall,
including the mesorectal fascia. The mesorectal fas-
cia represents a crucial landmark in the assessment
of rectal cancer, as it is the circumferential resection
margin for a total mesorectal excision of the rec-
tum. It has been demonstrated that the involvement
HEBK001-C03_p52-57.indd 55
References  55
of the mesorectal fascia is more informative than T
stage alone in determining the resectability of a rec-
tal tumour,46,47 thereby influencing the decision for
neoadjuvant chemoradiotherapy. The pelvic side-
wall lymph nodes are also typically outside the field
of view of the EUS probes, and so other imaging
modalities will be required to fully stage this region
to adequately plan treatment.
CONCLUSION
The management of rectal cancer is complex,
requiring decisions to be made as to the require-
ment for neoadjuvant therapies and the ability to
perform sphincter-sparing surgery. Endorectal
ultrasound is accurate for T staging of tumours
and is particularly accurate in early disease, where it
may be possible for selected patients to avoid resec-
tional surgery. It also appears to have a promising
role in the assessment of tumour relationship to the
components of the anal sphincter complex and may
develop a complementary role to MRI in the analy-
sis of cancers of this region. The development of
three-dimensional EUS may enhance the accuracy
of EUS in these roles.
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40. Santoro GA, Gizzi G, Pellegrini L, Battistella G,
Di Falco G. The value of high-resolution three-­
dimensional endorectal ultrasonography in the man-
agement of submucosal invasive rectal tumors. Dis
Colon Rectum 2009; 52: 1837–43.
41. Murad-Regadas SM, Regadas FS, Rodrigues LV, et al.
Role of three-dimensional anorectal ultrasonography
in the assessment of rectal cancer after neoadjuvant
radiochemotherapy: preliminary results. Surg Endosc
2009; 23: 1286–91.
42. Saranovic D, Barisic G, Krivokapic Z, Masulovic D,
Djuric-Stefanovic A. Endoanal ultrasound evaluation
of anorectal diseases and disorders: technique,
HEBK001-C03_p52-57.indd 57
References  57
indications, results and limitations. Eur J Radiol 2007;
61: 480–9.
43. Manger T, Stroh C. Accuracy of endorectal ultrasonog-
raphy in the preoperative staging of rectal cancer. Tech
Coloproctol 2004; 8: s14–15.
44. Hashimoto BE. Possible invasive rectal wall mass or
anal sphincter break. In Sanders RC, Winter TC (eds).
Clinical Sonography: A Practical Guide. Philadelphia,
PA, Lippincott Williams & Wilkins, 2006: 203.
45. Harewood GC. Assessment of publication bias in the
reporting of EUS performance in staging rectal cancer.
Am J Gastroenterol 2005; 100: 808–16.
46. Wolberink SV, Beets-Tan RG, Nagtegaal ID, Wiggers T.
Preoperative assessment of the circumferential margin
in rectal cancer is more informative in treatment plan-
ning than the T stage. Techn Coloproctol 2006; 10:
171–6.
47. MERCURY Study Group. Diagnostic accuracy of
preoperative magnetic resonance imaging in predict-
ing curative resection of rectal cancer: prospective
observational study. BMJ 2006; 333: 779.
08/02/13 6:41 PM

Magnetic resonance imaging staging
of rectal cancer
Peter How and Gina Brown
Introduction
Rectal cancer is common, and accurate preopera-
tive staging of tumours using high-resolution mag-
netic resonance imaging (MRI) is a crucial part of
modern multidisciplinary team management. The
importance of MRI in staging rectal cancer relates
specifically to the ability to delineate tumour exten-
sion with respect to surgically relevant landmarks,
primarily the mesorectal fascia and sphincter com-
plex. This has significant therapeutic implications
regarding the need or otherwise for neoadjuvant
therapy, sphincter preservation and plane of sur-
gery that can have a major impact upon the pa-
tient’s survival and quality of life. With the develop-
ment of effective coil systems and high-resolution
surface body coils, MRI looks likely to maintain and
expand its current position as the imaging modality
of choice for planning an effective therapeutic strat-
egy in patients with advanced rectal cancer.
MRI and surgical planning
for rectal cancer
Undoubtedly, the most important advance with-
in rectal cancer surgery over the past 30 years has
been the development of total mesorectal exci-
sion (TME). Described by Heald and colleagues in
HEBK001-C04_p58-70.indd 58
4
1982,1 TME involves the meticulous dissection and
complete removal of an intact surgical specimen
containing the tumour-bearing rectum surrounded
by the mesorectum, the embryologically derived
lymphovascular envelope of the human rectum.1,2
The principles of TME are outlined in Chapter 7
and are based on the following principles:
l The rectum is surrounded by the mesorectum
and an areolar tissue, the mesorectal fascia, that
forms a surgically distinct avascular plane.
l Perimesorectal plane dissection should result in
complete removal of the mesorectum contained
within an intact fascia.
l Careful dissection of the mesorectal fascia
allows identification and preservation of the
autonomic nerves, important for genitourinary
function.
In addition, anal sphincter preservation by ante-
rior resection is generally favoured where feasible, as
it avoids the need for a permanent stoma and is gen-
erally considered oncologically superior to sphincter
removal at abdominoperineal excision.3 TME fa-
cilitates restorative resection. Since the adoption of
TME, the mesorectal fascia has come to be synony-
mous with the circumferential resection margin, and
tumours located within 1 mm of this margin are con-
sidered to be margin-positive and at high risk of lo-
cal recurrence. Brown and colleagues demonstrated
08/02/13 6:40 PM

Figure 4.1. Depiction of rectal tumour (red line) relative
to the mesorectal fascia (blue line) on axial magnetic
resonance imaging.
the feasibility and reproducibility of identifying such
high-risk tumours on MRI by accurately depicting
the proximity of the tumour to the mesorectal fascia
(Figure 4.1).4 This is a key determinant for success-
ful treatment of rectal cancer, as it is this relationship
that often dictates the use of neoadjuvant therapy
and helps determine the optimal surgical plane. In
cases where tumour extends to or goes through the
mesorectal fascia, the TME or ‘holy plane’ is deemed
unsafe; neoadjuvant therapy (preoperative radio- or
chemoradiotherapy) or an extended surgical proce-
dure, or a combination of both, may then be required
to achieve a clear circumferential resection margin.
In a low rectal cancer, an enhanced extralevator ap-
proach may be needed. Such radiological guidance
is of particular interest with respect to tumours of
the lower rectum where the mesorectum tapers as it
approaches the pelvic floor. It is here where breaches
of the mesorectal fascia and infiltration of the leva-
tor are often observed in advanced tumours. This is
outlined in detail later.
In addition to the mesorectal fascia, the proxim-
ity of the tumour to other important pelvic viscera
plays an important role in surgical planning. These
viscera include the prostate, seminal vesicles, bladder,
uterus and vagina. Curative resection may depend on
removing parts or all of these adjacent structures in
locally advanced tumours. Where tumour extends
to or invades these structures, conventional surgery
(anterior resection or abdominoperineal excision)
will result in cutting through the tumour, and a more
radical surgical approach such as pelvic exenteration
may be required.
HEBK001-C04_p58-70.indd 59
ANATOMICAL LANDMARKS  59
ANATOMICAL LANDMARKS
The important anatomical structures to consider in
rectal cancer surgery, some or all of which may be
visualized on MRI, are:
l normal rectal wall;
l mesorectum and mesorectal fascia;
l anal sphincter complex;
l Denonvilliers’ fascia/urogenital septum;
l presacral fascia;
l peritoneal reflection;
l pelvic nerve plexuses.
Normal Rectal Wall
The rectal wall, in keeping with the rest of the large
bowel, is composed of an inner mucosal layer, con-
centrically surrounded by submucosa and the mus-
cularis propria, comprising an inner circular and
outer longitudinal layer. Interposed between the
two muscle layers lies the myenteric plexus con-
tained within a thin layer of connective tissue.
The mucosal layer on MRI is represented by a del-
icate low-signal intensity line, with the submucosal
layer beneath this depicted as a thicker higher-signal
intensity structure. With high-quality images, the
muscularis propria can sometimes be visualized as
two distinct layers of circular and longitudinal mus-
cle. The outer muscle layer often has an irregular
ridged appearance on account of blood vessels enter-
ing the rectal wall. The perirectal fat appears as high-
signal-intensity tissue, contrasting well with the low
signal of the muscularis propria (Figure 4.2).
Mesorectal Fascia and Mesorectum
The mesorectal fascia is best seen on axial images
and appears as a low-signal intensity linear struc-
ture surrounding the mesorectum (Figure 4.3). In-
feriorly, this layer fuses with the endopelvic fascia
that lies over the surface of the levator muscles; su-
periorly, the fascia fuses with the peritoneal reflec-
tion anteriorly and parietal fascia posteriorly.
The mesorectum on MRI axial images appears as
a high-signal intensity (similar to fat) package sur-
rounding the rectum, containing blood vessels and
lymphatic tissue. Lymph nodes within the mesorec-
tum appear as high-signal intensity ovoid structures.
08/02/13 6:40 PM
 60  MRI staging of rectal cancer

ICM, inner circular muscle; M, mucosa; OLM, outer longitudinal muscle; SM, submucosa.
Figure 4.2. Layers of the bowel wall as they appear on magnetic resonance imaging and on histopathology.

Anal Sphincter Complex important for continence (i.e. internal and external
sphincter, puborectalis, levator plate) (Figure 4.4).
The anal canal is composed of inner circular smooth
muscle forming the internal sphincter, surrounded Denonvilliers’ Fascia/Urogenital Septum
by skeletal muscle forming the external sphincter.
The anal canal is seen as a cylindrical structure that Denonvilliers’ fascia or the urogenital septum (see
extends from the insertion of the puborectalis sling Chapter 7) forms a distinctive anterior structure,
on to the rectum to the external anal orifice. The more prominent in the male. The fascia represents
lower portion of the levator ani and external anal
sphincter are anatomically indistinguishable (see
Chapter 2). With high-quality T2 coronal and axial
images, it is possible to accurately depict tumour
proximity to the sphincter complex and delineate
individual components of the sphincter complex

EAS, external anal sphincter; IAS, internal anal sphincter.

Figure 4.3. Mesorectal fascia (blue line) surrounding Figure 4.4. Coronal image showing relationship of tumour
mesorectum and benign lymph node (arrow). (red) to sphincter complex and its components.

HEBK001-C04_p58-70.indd 60 08/02/13 6:41 PM


Figure 4.5. Axial T2-weighted image showing
Denonvilliers’ fascia as a low-signal layer.
a barrier to the spread of anterior tumours and
separates the rectum and perirectal structures from
the urogenital organs. It consists of a fibromuscular
structure composed of a number of layers that are
fused together and envelope the seminal vesicles. De-
nonvilliers’ fascia is visible on MRI as a low-signal
layer that can be traced up to the peritoneum supe-
riorly (Figure 4.5).
Presacral Fascia
The presacral fascia appears on sagittal MRI as a low-
signal intensity linear structure overlying the presacral
vessels (Figure 4.6). The presacral fascia lies posterior
to the mesorectal fascia. It is a thickened parietal fascia
covering the presacral veins and fat. It fuses with and
directly covers the muscles and vessels of the pelvic
Figure 4.6. Sagittal magnetic resonance imaging showing the
presacral fascia as a low-signal-intensity linear structure.
HEBK001-C04_p58-70.indd 61
ANATOMICAL LANDMARKS  61
side-wall. The pelvic side-wall contains a conglomera-
tion of lymph nodes that are related to branches of the
internal and external iliac vessels and are therefore in
a separate compartment from the mesorectum. The
pelvic side-wall nodes are therefore not routinely vis-
ualized in rectal cancer surgery unless this compart-
ment is opened up by dissecting through the presacral
or parietal fascia (see Chapter 7, p. 103).
Peritoneal Reflection
On sagittal MRI, the peritoneal reflection appears as
a low-signal intensity linear structure that extends
over the surface of the bladder and can be traced pos-
teriorly to its point of attachment on to the rectum.
On axial section, this point of attachment gives a V-
shaped configuration, with the anterior covering of
the rectum by the peritoneal reflection widening in the
cranial direction. It is important to note that the peri-
toneal covering of the rectum is not a surgical resec-
tion margin, as there is no adjacent structure – hence,
tumour extending to within 1 mm of the peritoneum
should not be considered as a potentially involved cir-
cumferential resection margin, although of course the
margin of the specimen removed may well be involved
with spread through the peritoneum and a high risk
of subsequent peritoneal carcinomatosis (Figure 4.7).
Pelvic Nerve Plexuses
Preservation of the autonomic nerve plexuses is cru-
cial if genitourinary dysfunction is to be avoided.
Figure 4.7. Sagittal magnetic resonance imaging
demonstrating the peritoneal reflection as a low-signal
V-shaped linear structure extending over the bladder to the
rectum.
08/02/13 6:41 PM
 62  MRI staging of rectal cancer

The superior hypogastric plexus, situated below the

bifurcation of the aorta, gives rise to the right and
left hypogastric nerves that descend to join the in-
ferior hypogastric plexus. The right and left inferior
hypogastric plexus lie in a parasagittal plane on the
pelvic side-wall. In males, the inferior hypogastric
plexus lies posterolaterally to the seminal vesicles; in
females, its anterior half lies against the upper third
of the vagina. On MRI, the inferior hypogastric plex-
us lies inside and medial to the vessels on the pelvic
side-wall but outside the mesorectal plane. The in-
ferior hypogastric plexus is a distinctive rectangular
fenestrated structure, typically 3–4 cm in anteropos-
terior length, lying in a parasagittal plane that can
often be identified on MRI due to its high-signal
intensity (Figure 4.8). By contrast, on axial and coro-
nal oblique imaging, the plexus appears as a linear
beaded structure.

STAGING RECTAL TUMOURS

Tumour staging is critical for planning of therapy

and determining likely prognosis with regard to lo-
cal recurrence and survival. To develop an effective
therapeutic strategy based on the patient’s indi-
vidual circumstances, discussion of MRI staging in
a multidisciplinary team context is key. It has been
reported that multidisciplinary team discussion of
preoperative MRI with implementation of a selec-
tive preoperative strategy significantly reduces R1
and R2 resections.5 For most cancers, tumour ex-
tension at diagnosis and treatment determines the Figure 4.8. Inferior hypogastric plexus appears as a
high-signal beaded structure on paracoronal (A) and axial
likelihood of cure; this is particularly relevant to
(B) imaging.
rectal cancer, where local and systemic recurrence
are major issues. Cuthbert Dukes highlighted the
importance of extramural spread in predicting lo- Like the Dukes system, the TNM system is a patho-
cal recurrence and survival in patients with rectal logically based system; the prefix ‘p’ indicates ‘patho-
cancer.6 The system he described has stood the test logical’ (e.g. pT1 indicates a T1 tumour at pathology).
of time; the so-called ‘Dukes classification’ focuses The main advantage of the TNM system is its universal
on two key aspects – the local extent of the tumour applicability and the ability to predict the likely stage
in relationship to the bowel wall, and the pres- at preoperative imaging and alter the management
ence or absence of lymph nodal involvement. The appropriately. In rectal cancer, a T1 rectal carcinoma
Dukes system was based on the excised specimen is limited to the submucosa and on MRI is depicted
subjected to pathological analysis and subsequent by intermediate signal intensity within the mucosa
staging. Currently, however, rectal cancer staging and submucosa, with preservation of a thin layer of
is based mostly on the tumour–node–metastasis submucosa lying deep to the tumour. The MRI appear-
(TNM) and Union for International Cancer Con- ances of such a tumour should be recorded as ‘mrT1’.
trol (UICC) staging systems, which have largely su- A T2 tumour invades the muscularis propria and
perseded the Dukes classification. on MRI corresponds to tumour signal extending into

HEBK001-C04_p58-70.indd 62 08/02/13 6:41 PM


the circular muscle, but without extending through
the full thickness of muscle. Where the full thickness
of the muscle coat is replaced by intermediate signal
intensity, this would equate with a T2 or T3 tumour,
which can be impossible to differentiate on MRI. A T3
rectal cancer extends beyond the muscularis propria
and is depicted on MRI by a broad-based infiltrative
margin of intermediate signal intensity, extending into
perirectal fat. Clearly, however, T3 cancers are a very
heterogeneous group, including tumours of variable
prognostic significance related to the depth of extra-
mural spread.7 More recent versions of the TNM stag-
ing system have sought to rectify this problem with
the introduction of subgroups T3a (, 1 mm beyond
muscularis propria), T3b (1–5 mm beyond muscula-
ris propria), T3c (5–15 mm beyond muscularis pro-
pria) and T3d (. 15 mm beyond muscularis propria),
which have prognostic significance.8 T4 rectal cancers
are defined as tumours that involve the peritoneal sur-
face or invades adjacent organs.
Imaging Technique
MRI rectal cancer staging is relatively fast and
straightforward, because no special patient prepara-
tion is required. Some centres advocate the use of an
antispasmodic agent such as hyoscine butylbromide
to prevent artefacts caused by small bowel peristal-
sis and to help distend the sigmoid and rectum.14 To
effectively plan the initial localization sequences, it
is important for the radiologist or radiographer to
know the approximate tumour height on clinical as-
sessment. The patient is then positioned on his or her
back and a phased-array surface coil is placed on the
pelvis, such that the edge of the coil is situated a good
distance below the pubic bone. The coil is secured
with belts and the patient is advanced head first into
the magnetic field.
The first series of localization images is the sagit-
tal T2W-FSE, which identifies the primary tumour.
The second series consists of large field-of-view
axial sections of the whole pelvis, extending from
the iliac crest to the pubic symphysis. The sagittal
T2-weighted images are used to plan T2-weighted
thin-section axial images through the rectal cancer
and along the rectum down to the anus, while en-
compassing perirectal tissues including important
pelvic landmarks. The images are achieved using
3 mm sections and a 16 cm field of view.
HEBK001-C04_p58-70.indd 63
STAGING RECTAL TUMOURS  63
The abrupt change in size of the rectal lumen
at the anorectal junction limits the usefulness of
oblique axial imaging performed proximally. Be-
yond the anorectal junction, axial imaging cannot
demonstrate the rectal wall in its entirety and is un-
able to reliably determine separation of the rectal
wall from the levator plate. This appearance could
lead to potential overstaging of tumours. A high-­
resolution coronal imaging sequence, however, can
accurately depict the levator, sphincter complex
and intersphincteric plane, which has important
surgical implications.
mrT Staging
It is widely accepted that MRI is the imaging mo-
dality that offers the highest soft-tissue contrast and
is therefore best suited to T staging rectal cancer.
Initial results with MRI were disappointing due
to poor spatial resolution achieved by whole-body
coil systems. The development of endorectal coils
improved resolution with T staging accuracies com-
parable to endorectal ultrasound, widely regarded
as the gold standard for assessing local invasion
of an early rectal cancer. As with endorectal ultra-
sound, however, endorectal MRI imaging is lim-
ited by a small field of view that permits adequate
evaluation only of early-stage rectal cancer, and not
advanced cancers, as visualization of surrounding
pelvic anatomy is limited. The other major disad-
vantage of endoluminal techniques relates to the
invasive nature; technical limitations such as steno-
sis, stricturing, pain, discomfort, bowel wall move-
ment and coil migration may render the acquisition
of good-quality images impossible, particularly in
advanced tumours.
The major breakthrough in MRI rectal can-
cer staging came with the development of high-­
resolution phased-array surface-coil systems.
These surface coils can achieve a very high spatial
contrast resolution while maintaining a large field
of view, enabling both accurate depiction of the in-
testinal wall and important surrounding anatomy,
including the mesorectal fascia. In recent studies,
reported accuracy has varied from 86 per cent to
100 per cent;9–11 such variability largely reflects the
difficulties in staging borderline tumours as T2 or
T3. It is well recognized that overstaging T2 tu-
mours is often caused by a desmoplastic reaction
08/02/13 6:41 PM
 64  MRI staging of rectal cancer
of peritumoural tissue.12 The most clinically rel-
evant feature of MRI, however, relates to its assess-
ment of the mesorectal fascia and thus the poten-
tial circumferential resection margin in a patient
undergoing a TME. The multicentre MERCURY
study revealed MRI to be accurate within 0.5 mm
in predicting local tumour spread and specificity
for prediction of a clear margin by MRI to be 92
per cent.13
N Staging
As with extent of extramural invasion, Dukes was
one of the first to identify lymph node involvement
as having significant prognostic value, with 5-year
survival being related to the number of affected
nodes.19 A number of studies have demonstrated
that the involvement of four or more nodes signifi-
cantly worsens survival and highlights the impor-
tance of adequate lymph node dissection during
surgery and histopathological assessment. Current
guidelines from the Royal College of Pathologists
recommend that an average of more than 12 nodes
should be sampled for all surgical specimens con-
taining cancer.
Predicting involvement of the lymph nodes on
preoperative imaging has been considered by many
to be a crucial but challenging task in rectal cancer
staging. Accuracy rates for N staging reported in
the literature show wide variation across all recog-
nized imaging techniques. The reported accuracy
for MRI ranges from 57 per cent to 85 per cent.20–23
Although it is impossible for any form of preop-
erative imaging to reliably exclude microscopic
nodal involvement, the high-contrast resolution
images offered by MRI have enabled the identifi-
cation of consistent markers for lymph nodal in-
volvement. Brown and colleagues demonstrated
that an irregular contour and an inhomogeneous
signal are the most reliable MRI criteria for lymph
node metastasis when comparing preoperative
MRI with histopathological assessment of the re-
sected specimen (Figure 4.9).23 Conversely, normal
or reactive nodes are characterized by uniform
signal intensity and smooth, well-defined borders.
Although it is natural to suspect that enlarged
nodes are likely to be malignant, using size crite-
ria alone would result in a high number of false
positives. Considerable overlap in size between
HEBK001-C04_p58-70.indd 64
benign, reactive and malignant nodes has been
observed; Brown and colleagues23 have reported
that a previously purported cut-off size of 5 mm
to differentiate involved from uninvolved nodes22
is unfounded. The importance of preoperative N
staging is not limited to its prognostic value with
regard to systemic recurrence, because lymph
nodal involvement has also been linked to an in-
creased local recurrence. The presence of involved
lymph nodes close to the mesorectal fascia (cir-
cumferential resection margin in a patient with an
upper or middle rectal cancer having a TME) has
been reported to increase the risk of local recur-
rence,24 and many units consider suspicious nodes
near to the mesorectal fascia to be an indication
for neoadjuvant therapy. A publication from 2010
evaluated the importance of nodes near to the
mesorectal fascia detected on MRI and correlated
whether this resulted in a positive circumferential
resection margin. In a retrospective review of 396
patients with rectal cancer, Shihab and colleagues
identified 31 patients with suspicious nodes 1 mm
or less from the circumferential resection margin.
None of these patients had a positive circumfer-
ential resection margin owing to nodal involve-
ment.25 This would suggest that with regard to
nodes threatening the circumferential resection
margin, only those with obvious extracapsular ex-
tension will result in a positive margin and would
therefore require neoadjuvant therapy.
Pelvic Side-Wall Nodal Disease
The use of 16 cm field-of-view thin-section MRI
enables the pelvic side-wall compartment and the
mesorectal compartment to be assessed. This is
of particular value in identifying patients at risk
of residual disease, despite a successful TME op-
eration, due to pelvic side-wall nodal disease. It is
generally thought that pelvic side-wall disease is a
feature of aggressive disease and associated with
poor survival.26 Undoubtedly involved nodes are
more common in patients with low rectal cancer.
In the UK and Europe, pelvic side-wall nodal dis-
section is seldom performed because of the unac-
ceptable morbidity related to this operation. Cur-
rently in the West, a high risk of suspicious pelvic
side-wall nodal involvement is generally treated by
targeted radiotherapy or chemoradiotherapy.
08/02/13 6:41 PM

Figure 4.9. Irregular contour and inhomogeneous signal are the most reliable magnetic resonance imaging (MRI) criteria
for lymph node metastasis on MRI/histopathological comparison.
Vascular Spread
Extramural vascular invasion (EMVI) is defined as
the presence of malignant cells within blood vessels
beyond the muscularis propria in the vicinity of a
colorectal tumour. Histological EMVI has long been
recognized as an independent predictor of ­local and
systemic recurrence and poorer overall survival27–29
and has been reported to occur in up to 52 per cent of
all cases of colorectal cancer.30–34 Extramural vascular
invasion is therefore considered an adverse prognos-
tic feature and by some is considered an indication
for neoadjuvant therapy, despite the circumferential
resection margin remaining unthreatened by the
primary tumour. Although MRI can detect EMVI,
only recently have the radiological characteristics of
EMVI been documented adequately. This characteri-
zation is important as it is not always possible to de-
termine with absolute certainty whether a structure
is vascular. Larger vessels on T2-weighted images
may appear black due to signal void, while smaller
vessels may be recognized because of tortuosity and
branching, but there is a general lack of consistency
of radiological features. In response to this, Smith
and colleagues defined four criteria by which MRI-­
predicted EMVI should be assessed:35
l Pattern of tumour margin: tumour invasion into
small veins that radiate outward from the bowel
wall produces a nodular border that can be
distinguished from desmoplasia, which appears
as fine stranding of low-signal intensity.
HEBK001-C04_p58-70.indd 65
STAGING RECTAL TUMOURS  65
l Location of tumour relative to major vessels:
presence of tumour signal within a vascular
structure is highly suggestive of EMVI.
l Calibre of vessel: as tumour invades along the
lumen, the vessel expands. Tumour signal is
intermediate (grey), and hence expansion of a
low-signal vessel by tumour extension is readily
identifiable.
l Vessel border: tumour may eventually expand
through the vessel wall to give variable results;
the border may be smooth, irregular or nodular.
Based on these criteria, a five-point grading sys-
tem (0 to 4) for MRI-predicted EMVI has been pro-
posed, with the lowest score (0) corresponding to
an absence of suspicious features and the highest
score (4) corresponding to the most overt features
(Figure 4.10).
A subsequent study comparing MRI and his-
topathological assessment of EMVI has demon-
strated sensitivity and specificity of MRI to be 62
per cent and 88 per cent, respectively (Figure 4.11).36
Furthermore, relapse-free survival at 3 years was
reported at 35 per cent for patients with an MRI-
EMVI score of 3–4 compared with 74 per cent for
patients with an MRI-EMVI score of 0–2. Amalga-
mating five separate scores (0, 1, 2, 3, 4) into these
two broader groups (0–2, 3–4) achieved a similar
prediction of relapse-free survival as histopatho-
logical assessment of EMVI (34 per cent versus 74
per cent). MRI-predicted EMVI can therefore help
predict disease recurrence and is an important part
08/02/13 6:41 PM
 66  MRI staging of rectal cancer

MRI-
EMVI Imaging features Illustration
score

Minimal extramural stranding/nodular

1 extension seen, but not in the vicinity
of any vascular structures.

Stranding demostrated in the vicinity

of extramural vessels, but these
2 vessels are of normal calibre, and
there is no definite tumour signal
seen within the vessel.

Intermediate signal intensity apparent

3 within vessels, although the contour
and calibre of these vessels is only
slightly expanded

Obvious irregular vessel contour or

4 nodular expansion of vessel by definite
tumour signal.

Figure 4.10. Five-point grading system for magnetic resonance imaging-predicted extramural vascular invasion.

of preoperative staging. Although EMVI does pre-
dict for an increased risk of local recurrence, the real
issue is the very high risk of systemic recurrence; in
future, patients with MRI-detected EMVI may be
treated with neoadjuvant chemotherapy rather than
neoadjuvant chemoradiotherapy.
It has also been demonstrated, however, that a
greater proportion of patients with rectal cancer
with MRI-predicted EMVI also have MRI-predicted
pelvic side-wall disease. As alluded to earlier, af-
fected PSW nodes are generally associated with
disseminated systemic disease and in the West are
an indication for neoadjuvant therapy. Lower rec-
tal tumours in particular are noted to have a much
higher incidence of PSW disease compared with
mid- and upper tumours,37,38 thought to be related
to differing patterns of lymphatic drainage.
Low Rectal Cancer and an
Anatomically Based Staging System
Low rectal cancer, as defined by a tumour with
its lower edge at or below the origin of the leva-
tors at the pelvic side-wall, usually corresponds to
a tumour within 6 cm from the anal verge. At this
level, the mesorectum tapers out and the safety net
of the mesorectum is lost. Thus, tumours at this

HEBK001-C04_p58-70.indd 66 08/02/13 6:41 PM


Figure 4.11. Magnetic resonance imaging (MRI) and histopathological assessments of MRI.
level are more likely to involve the sphincters and
neighbouring structures, and surgical treatment
is more problematic. For example, extramural ex-
tension located anteriorly is likely to infiltrate the
prostate and may require clearance of the anterior
compartment; similar extramural extension locat-
ed posteriorly may be amenable to surgical cure by
conventional TME, even for low tumours. Indeed,
although preoperative staging techniques are lim-
ited in differentiating between T2 and early T3 tu-
mours, this has minimal therapeutic implications
in the mid- and upper rectum, given that both have
a good prognosis with optimal curative surgery and
neoadjuvant therapy is not generally required. The
low rectum is more complex because of anatomical
constraints and the lack of mesorectum as a natural
barrier and safety net.
Unsurprisingly, interest is growing in anatomically
based staging classifications that can accurately pre-
dict whether a tumour-free circumferential resection
margin is likely to be achieved or not, regardless of the
T stage. This would enable discrimination between
patients with minimal mesorectal infiltration not re-
quiring neoadjuvant therapy and those with threat-
ened or infiltrated mesorectal fascia who would ben-
efit from neoadjuvant therapy. Furthermore, such a
system may help identify patients in whom a modi-
fied surgical approach is required such as the extra-
levator abdominoperineal excision (Figure 4.12) (see
Chapter 8, p. 125).
HEBK001-C04_p58-70.indd 67
STAGING RECTAL TUMOURS  67
The complexity of low rectal cancer has stimu-
lated increasing interest in assessment and manage-
ment of cancers in the distal rectum. At the time
of writing, the English National Cancer Action
Team has funded the Low Rectal Cancer National
Development Programme aiming to improve can-
cer outcomes and quality of life in patients with
low rectal cancer. Some of the key objectives are
to enhance patient-centred multidisciplinary team
decision-making to improve patient outcome and
quality of life by optimal preoperative therapy and
surgical technique. Shihab and colleagues describe
a two-plane approach to low rectal cancer – the
­mesorectal and extralevator planes.15,16 In response
to the apparent oncological inferiority of the tra-
ditional abdominoperineal excision compared with
low anterior resection in the management of low
rectal cancer, the authors proposed a modified ap-
proach to abdominoperineal excision, as outlined
in Chapter 8. Histopathological studies have dem-
onstrated a reduction in circumferential resection
margin positivity and specimen perforation rates
with this approach,17 but possibly more perineal
wound complications,18 highlighting the impor-
tance of appropriate patient selection.
Shihab and colleagues advise that for low tumours
located above the sphincters and more than 1 mm
from the mesorectal fascia, the mesorectal plane
may be appropriate and adequate.15,16 Similarly, for
tumours at the anal canal, the mesorectal plane is
08/02/13 6:41 PM
 68  MRI staging of rectal cancer

Resection lines
Level at which resection lines meet
Figure 4.12. The extralevator abdominoperineal excision, whereby perineal dissection is performed outside the levators,
which are divided close to their origin at the pelvic side-wall, with removal en bloc of the rectum and anus.

safe for those that show partial invasion or less of
the internal sphincter – that is, the intersphincteric
plane is not involved or threatened (Figure 4.13).
Although the extralevator abdominoperineal exci-
sion remains a topic for debate, the authors seek to
define the excision planes for this operation and,
in so doing, offer appropriate selection criteria; the
main indication is for low rectal tumours above the
sphincters that are predicted to invade the levator
muscle or invade the full thickness of the internal
anal sphincter, or beyond this, at the level of the
sphincters.
Given that MRI can often accurately depict com-
ponent parts of the sphincter complex and lower
rectum described earlier, a novel staging system for
low rectal cancer has been proposed.15,16 In keeping
with the aforementioned surgical planes, this sys-
tem divides the lower rectum into suprasphincteric

Mesorectal
fascia

Levator
1
insertion

Puborectalis and
Intersphinteric external sphincter
Figure 4.13. A novel magnetic plane
resonance imaging-based staging
2
system for low rectal cancer based Internal
sphincter
on key anatomical landmarks of the
sphincter complex.

HEBK001-C04_p58-70.indd 68 08/02/13 6:41 PM


and sphincteric compartments, with clear selec-
tion criteria as to which plane of surgery may be
appropriate, safe and effective. Retrospective evalu-
ation of this staging system has yielded promising
results, and prospective larger-scale studies are un-
der way. It is hoped that this novel MRI-based stag-
ing system will help reduce circumferential resec-
tion margin positivity for low rectal cancers by the
selective use of neoadjuvant therapy and planned
surgery.
CONCLUSION
The development of high-resolution MRI surface-coil
systems has resulted in accurate preoperative staging,
which has marked a new era in rectal cancer manage-
ment. Since the widespread adoption of TME, more
attention is being devoted to staging systems that can
accurately predict circumferential resection margin
status and reliably determine selective use of neoad-
juvant therapy or suggest an alternative surgical ap-
proach. Despite its limitations in T staging, MRI is
currently the only imaging modality capable of de-
picting the topographic relationship between tumour
and the proposed surgical resection margin. Low
rectal cancer in particular is more complex and with
worse outcomes than middle and upper rectal cancer
and is currently the focus of ongoing attempts to im-
prove all aspects of management, including improved
MRI staging based on key anatomical landmarks. Op-
timal staging, enhanced decision-making regarding
preoperative therapy and optimal surgery will lead to
improved oncological outcomes.
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379–89.
15. Shihab OC, Heald RJ, Rullier E, et al. Defining the
surgical planes on MRI improves surgery for cancer of
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MRI staging of low rectal cancer. Eur Radiol 2009; 19:
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17. West NP, Finan PJ, Anderin C, et al. Evidence of the
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18. West NP, Anderin C, Smith KJ, et al. Multicentre
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imaging in preoperative staging of rectal cancer. Dis
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Christensen N. Venous and nerve invasion as prog-
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35. Smith NJ, Shihab O, Arnaout A, Swift RI, Brown G.
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08/02/13 6:41 PM

Radiological staging for
systemic disease
Gina Brown and Chris Hunter
Introduction
The early accurate identification of metastatic
disease is becoming increasingly important
in rectal cancer, in both the preoperative and
follow-up settings. A proportion of patients
undergoing resection of metastatic disease now
achieve long-term cure. 1 It is now well estab-
lished that patients undergoing surgery for
resectable liver metastases achieve a 5-year sur-
vival in the region or in excess of 40 per cent,
compared with almost no survivors at 5 years
for untreated patients.1–4 The proportion of
patients in whom long-term cure is achieved
following metastasectomy has increased over
time, with more recent studies demonstrating
5-year survival approaching 50 per cent in some
patients. 5 This is due in part to more accurate
preoperative imaging allowing better patient
selection.6,7
The early detection of metastatic disease
increases the likelihood of identifying resectable
disease. In the follow-up setting, it has been shown
that the early detection of metastatic disease is of
benefit in addition to informing patients of prog-
nosis.8 Intensive follow-up regimes that include
computed tomography (CT) identify local or
distant recurrence 8.5 months earlier than those
using clinical follow-up and carcinoembryonic
HEBK001-C05_p71-86.indd 71
5
antigen (CEA) alone, and 5-year survival is
improved from 9 per cent to 13 per cent.9
The patient group in which metastasecto-
my may be indicated also continues to expand.
Improvements in surgical technique have result-
ed in low operative morbidity and mortality asso-
ciated with metastasectomy, and metastasectomy
is increasingly offered to patients over 70 years
of age. Even after metastasectomy, continued
surveillance for further metastatic disease is of
benefit, as repeat metastasectomy may improve
survival.10,11
In a proportion of patients, even with optimal
surveillance, metastatic disease will be inoper-
able at the time of diagnosis. Patients with unre-
sectable metastatic disease treated with palliative
chemotherapy have better survival at 6 months and
12 months, however, compared with patients
treated with supportive care alone.12 Patients with
unresectable metastatic disease may also be selected
for palliative rather than aggressive surgical treat-
ment. Surgical palliation is an effective treatment
that alleviates symptoms, increases survival over
non-­surgical supportive care, and may require only
a short hospitalization.13
In this chapter we discuss the common mecha-
nisms and sites of metastasis in rectal cancer, and
the modalities available to identify metastases to
these sites.
08/02/13 5:59 PM
 72  Radiological staging for systemic disease
Mechanisms of spread of
colorectal metastases
Lymphatic Spread
Lymph nodes are the most common site of metas-
tasis in rectal cancer, with lymph node metastases
occurring in 51.9 per cent of 1732 patients under-
going resection of their primary rectal cancer in
the Dukes series.14 The incidence of lymph node
metastases increases with increasing histological
grade of the primary tumour, and with more local-
ly advanced tumours. Lymph node metastases usu-
ally spread progressively along the lymphatic chain
from lymph node to lymph node.
In rectal cancer, lymphatic spread is initially to
mesorectal lymph nodes adjacent to the primary
tumour. As metastases move up the lymph node
chain, they may follow the inferior or middle rec-
tal arteries to pelvic side-wall lymph nodes, par-
ticularly in low rectal cancer (usually within 6 cm
from the anal verge), and then the internal iliac
lymph node chain. The main lymphatic drainage is
to nodes along the superior rectal artery and thence to
nodes around the inferior mesenteric artery.15
If metastases block the usual lymphatic drain-
age, then retrograde spread of metastases through
the lymphatics may occur. This usually occurs only
in advanced tumours with multiple lymph node
metastases and is one of the mechanisms for spread
to pelvic side-wall and inguinal nodes.16 Spread
to inguinal lymph nodes in rectal cancer is rare
(occurring in approximately 2 per cent of patients)
and usually occurs only in low rectal cancers invad-
ing the anal canal.
Haematogenous Spread
Extramural vascular invasion has been known to
be a predisposing factor for the development of
distant metastases for some time.17–20 It is probable
that haematogenous spread is the main route for
visceral metastases.
It is therefore unsurprising that the most common
site for colorectal metastases is the liver, as the venous
drainage of the colon and rectum is primarily via
the portal vein. In a population-based study of 1325
patients, 18.8 per cent of patients had liver metastases
occurring within 6 months of diagnosis of colorectal
HEBK001-C05_p71-86.indd 72
cancer, and a further 10.5 per cent of patients devel-
oped metachronous metastases within 3 years.21 As
well as being the most common site of visceral metas-
tases in colorectal cancer, the liver is the only site of
visceral metastases in 30–40 per cent of patients.
Other, less common sites of distant metastases
in colorectal cancer are the lung (11 per cent of
patients have synchronous metastases and 5.8 per
cent of patients develop metachronous metastases
within 5 years),22 ovary (2–8 per cent of women
within 5 years),23,24 bone (5 per cent) and brain
(2 per cent).25
Other sites of colorectal metastases are rare but
include the spleen, kidneys, pancreas, adrenals,
breast, thyroid and skin. It appears, however, that
unusual sites of metastasis are becoming more
common with the increased use of systemic agents.
There also appears to be a relationship to the
number of systemic therapies received.26
Transcoelomic Spread
The third mechanism of metastasis encountered in
colorectal cancer is spread of tumour cells across
the peritoneal cavity. This usually occurs when
tumour has invaded through the peritoneum (T4
disease). This may be apparent on preoperative
imaging, macroscopically at the time of operation,
or on histopathological assessment postoperatively.
Occasionally, this form of spread may result from
peritoneal spillage of tumour cells at the time of
surgical resection.
Peritoneal deposits have a predilection for
certain sites within the abdominal cavity; these
include the superior and inferior paracolic
recesses, the rectovesical pouch (pouch of Doug-
las), the under surface of the diaphragm and the
transverse mesocolon.27–29
SITES OF METASTASES
IN COLORECTAL CANCER
Liver Metastases
As mentioned previously, the liver is the most com-
mon site for visceral colorectal metastases.
Figure 5.1 shows a contrast-enhanced CT demon-
strating liver metastases. Over the period from 1984
08/02/13 5:59 PM
 SITES OF METASTASES IN COLORECTAL CANCER   73
Figure 5.1. Contrast-enhanced computed tomography
demonstrating liver metastases (arrowheads).
to 2005, 5-year overall survival for patients undergo-
ing resection of hepatic metastases improved from
23 per cent to 46 per cent, despite patients undergo-
ing operations with more severe disease.30
Improved survival following treatment for
colorectal liver metastases has been attributed to
a number of different factors, including improved
techniques for anatomical resection,1,2,4 increased
use of intraoperative ultrasound,31,32 reduction in
perioperative morbidity and mortality,3 second
resections for recurrent hepatic metastases,33 and
the use of chemotherapy.34–37
Recent developments in interventional radiology
have also had a significant impact on the treatment of
colorectal liver metastases. Radiofrequency ablation
(RFA) now has a significant role. Although there is an
absence of evidence from randomized controlled tri-
als, due in part to the fact that the two attempted ran-
domized controlled trials of RFA closed early due to
poor recruitment, there is a growing body of evidence
from clinical series and non-randomized compara-
tive studies that supports the use of RFA. Although
resection of colorectal liver metastases remains the
treatment of choice in suitable patients, RFA is a use-
ful additional treatment modality for metastases of
less than 3–4 cm in size, with local recurrence rates
of 6.7–17 per cent.38–40 Mean and 5-year survival
with combined chemotherapy and RFA are better
than with either modality alone, and median survival
HEBK001-C05_p71-86.indd 73
of 24–59 months can be achieved in unresectable
colorectal liver metastases.41 This compares favour-
ably with median overall survival of 16–24 months
with chemotherapy alone. Figure 5.2 shows a hepatic
metastasis following RFA. Portal vein embolization
may be used to induce liver hypertrophy and allow
extended hepatectomy in patients who would other-
wise have insufficient functional reserve.42
A number of different studies have identified
risk factors that predict outcome after resection of
liver metastases. One of the largest studies includ-
ed more than 1000 patients and identified the fol-
lowing adverse prognostic factors: size of metasta-
sis .5 cm, potential involvement of the resection
margin, more than one liver metastasis, poor
prognosis primary, synchronous primary tumour
and liver metastases within 12 months, and extra-
hepatic metastatic disease. Overall 5-year survival
was 60 per cent with none of these risk factors,
falling to less than 20 per cent with four or more
risk factors.43
It is therefore very important to have accurate
preoperative imaging before treatment for liver
metastases for careful patient selection. The aims of
imaging for patients undergoing resection of liver
metastases are:
l to accurately demonstrate anatomical distribu-
tion of liver metastases and segmental sparing;
l to exclude widespread micro-metastatic disease
within the liver;
l to exclude extra-hepatic metastases;
l to discriminate between benign and malignant
liver lesions;
l to stratify patients in terms of prognosis follow-
ing metastasectomy.
When assessing patients preoperatively for occult
intra- or extra-hepatic malignancies, it is worth
bearing in mind that the risk is strongly related to
the number and distribution of hepatic metastases;
both occult intra-hepatic metastases and extra-
hepatic metastases are rare with solitary unilobar
metastases but much more common with multiple
bilobar metastases.44
Lung Metastases
The lungs are the second most common site of
metastasis in rectal cancer. If resection can be
08/02/13 5:59 PM
 74  Radiological staging for systemic disease
Figure 5.2. Liver magnetic resonance imaging demonstrating two metastases (in left lobe, black arrow; in right lobe,
white arrow. (A) Before treatment; (B) following chemotherapy; (C) following resection of larger metastasis; (D) following
radiofrequency ablation of smaller metastases.
undertaken safely, then excellent outcomes can
be achieved, with 5-year survival of 55.4–71 per
cent.45,46 Patients undergoing repeat thoracotomy for
recurrent pulmonary metastases may also achieve
good outcomes, but the presence of hilar or medias-
tinal lymph node involvement or extra-pulmonary
metastases is associated with a poor survival rate.11
As with liver metastases, it is therefore important to
identify lesions early, when curative resection may
still be achieved, and to exclude poor prognosis fea-
tures such as extra-pulmonary metastases and hilar
or mediastinal lymph node involvement.
Lung metastases usually present initially as small
nodules, which are often less than 5 mm in diam-
eter. Multidetector CT allows early detection and is
superior to any other modality in the detection of
these small lesions.47 Figure 5.3 illustrates pulmo-
nary metastases evident on thoracic CT. Although
HEBK001-C05_p71-86.indd 74
this results in the identification of more benign
lesions, a baseline CT and serial examinations allow
indeterminate lesions to be interpreted more confi-
dently during follow-up.
Ovarian Metastases
Ovarian metastases occur in 6–8 per cent of women
with colorectal cancer, making the ovaries the third
most common site of visceral metastases in women.
Radiologically, colorectal ovarian metastases may
be easily mistaken for primary mucinous adenocar-
cinoma of the ovary.48 It is therefore important that
the reporting radiologist is aware of any current or
previous diagnosis of colorectal cancer when inter-
preting radiological imaging. Colorectal ovarian
metastases may appear as large oval or lobulated,
08/02/13 5:59 PM
 IMAGING MODALITIES AVAILABLE FOR STAGING SYSTEMIC DISEASE  75

therefore usually occur in the presence of T4b

disease, where the serosa has been breached by
tumour.
The pattern of peritoneal spread is related to
tumour grade, with poorly differentiated tumours
tending to produce diffuse seeding and well-differen-
tiated tumours being more likely to produce solitary
deposits. Peritoneal metastases are the most common
cause of ureteric obstruction due to colorectal cancer
and should be considered when unexplained ureteric
obstruction is identified in patients with colorectal
cancer.
Although peritoneal metastases are usu-
ally managed palliatively, very carefully selected
patients may have a good outcome if treated sur-
gically,51,52 and so patients should be discussed in
a multidisciplinary setting if peritoneal disease
is identified. Figure 5.5 demonstrates peritoneal
Figure 5.3. Contrast-enhanced computed tomography
demonstrating lung metastasis (arrowhead).
metastases on CT.

cystic or solid ovarian masses.49,50 Figure 5.4 shows IMAGING MODALITIES AVAILABLE
a typical ovarian metastasis on CT. FOR STAGING SYSTEMIC DISEASE

The list of imaging modalities available for the

Peritoneal Metastases systemic staging of rectal cancers continues to
increase. No single imaging modality is currently
Peritoneal metastases occur through spread of optimal for identifying all distant metastases, how-
tumour cells across the peritoneal cavity. They ever, so a multimodality approach is necessary.

Figure 5.4. Unenhanced computed tomography Figure 5.5. Contrast-enhanced computed tomography
demonstrating bilateral ovarian metastases (arrowheads). demonstrating peritoneal metastases (arrowheads).

HEBK001-C05_p71-86.indd 75 08/02/13 5:59 PM

 76  Radiological staging for systemic disease
Computed Tomography
Computed tomography of the thorax, abdomen
and pelvis is the most common imaging technique
used for identifying distant metastases in rectal
cancer, in both primary staging and follow-up. It is
widely available, rapid and relatively cheap.
Despite the fact that colorectal cancer metasta-
sizes to the liver via the portal vein, colorectal liver
metastases derive their blood supply from the hepat-
ic artery.53 This fact can be exploited in the iden-
tification of liver metastases: liver CT performed
during peak hepatic enhancement will identify
most colorectal liver metastases due to their rela-
tive hypovascularity in this phase of enhancement.
A contrast-enhanced CT demonstrating hepatic
metastases is shown in Figure 5.1. This feature can
be exploited further using CT portography. In this
technique, the superior mesenteric artery is selec-
tively catheterized, and CT scanning of the liver is
performed approximately 60 s after the adminis-
tration of contrast material via the catheter. This
technique increases the sensitivity and specificity of
CT in the identification of colorectal metastases54
and has been used in the preoperative assessment
of patients being considered for hepatic metastasec-
tomy to delineate the disease extent. The technique
is invasive, however, and so has not been used in the
routine primary staging or follow-up of patients
with rectal cancer.
The steady improvements in CT technology
have also increased its accuracy in identifying liv-
er metastases. Improved sensitivity and specificity
in detecting colorectal liver metastases have been
attributed to the use of helical CT with 5-mm
­collimation.55 Using this technique in the preopera-
tive assessment of patients undergoing resection of
liver metastases, 94 per cent of patients selected for
resection by CT were resectable at operation, and
4-year survival was 58 per cent. Multidetector CT
represents further technological improvement and
is accurate in detecting lesions over 10 mm in size,
with 1 mm isotropic voxels giving improved spatial
resolution and the ability to reconstruct images in
any plane.56 This has largely removed the need for
CT portography, even in the preoperative assess-
ment for metastasectomy.
The advent of multidetector CT has also allowed
imaging of the whole liver in around 10 s. Multi-
detector CT allows assessment of the liver during
HEBK001-C05_p71-86.indd 76
multiple phases of enhancement in the same sitting,
by repeating images through the liver at different
time delays after the injection of contrast. There is
little evidence, however, that arterial phase imaging
is of significant benefit in colorectal metastases.57,58
Colorectal liver metastases typically appear as
hypointense lesions with a rim of enhancement.
Occasionally they may contain central necrosis
with a low-density ‘cystic’ centre. Liver cysts are the
most common benign lesions identified. These are
well-defined lesions with no rim of enhancement,
no internal structure and very low attenuation.59
Although it is often relatively easy to characterize
larger lesions, small liver lesions (, 10 mm) may be
more challenging. In these circumstances, interval
scanning or review of serial imaging is very impor-
tant. A 3 month interval CT scan improves specifi-
city from 90 per cent to 99 per cent.60
A meta-analysis from 2010 found that the per-
patient sensitivity of CT for detecting liver metas-
tases was 83.6 per cent.61 Computed tomography
is therefore a good baseline screening investigation
for distant metastases in patients with rectal cancer,
in both the preoperative and follow-up settings. It
may also identify patients with unresectable meta-
static disease who do not require further imaging.
In this study, however, the sensitivity of magnetic
resonance imaging (MRI) and 18F-fluorodeoxy-
glucose positron-emission tomography (18F-FDG-
PET) were both higher than that of CT. Computed
tomography also has limited ability to identify
small-volume peritoneal and liver surface disease.
Computed tomography is largely limited to size cri-
teria for the identification of distant nodal metas-
tases, which has limited sensitivity. Therefore, when
planning metastasectomy, or if there is a high index
of suspicion of metastatic disease and a normal CT,
other imaging modalities should also be employed.
18F-Fluorodeoxyglucose
Positron-emission Tomography
18F-Fluorodeoxyglucose positron-emission tom-
ography is a form of functional imaging that uses
an 18F labelled tracer, which is taken up by the glu-
cose receptor but not metabolized. The tracer accu-
mulates in cells with increased glucose metabolism
and upon decay releases high-energy photons,
which can be detected by dedicated receptors. As
08/02/13 5:59 PM
 IMAGING MODALITIES AVAILABLE FOR STAGING SYSTEMIC DISEASE  77
increased glucose metabolism is exhibited by many
tumour cells, this technique can be used to identify
primary and metastatic disease in rectal cancer.
There has been much interest in the use of 18F-FDG-
PET to identify metastatic disease in colorectal cancer.
In 2005, a meta-analysis of 61 eligible articles sug-
gested that on a per-patient basis, 18F-FDG-PET
was more sensitive than CT or MRI in detecting liver
metastases, with a sensitivity of 94.6 per cent, although
on a per-lesion basis superparamagnetic iron oxide
(SPIO)-enhanced MRI was more sensitive.62 Similar
results were found in a further meta-analysis in 2010,
where the sensitivity of 18F-FDG-PET for detect-
ing colorectal liver metastases on a per-patient basis
was 94.1 per cent and significantly higher than CT or
MRI;61 again, on a per-lesion basis, there was no sig-
nificant difference between MRI and 18F-FDG-PET,
and MRI was significantly better than CT in detecting
lesions under 1 cm in size.
A number of studies have also demonstrated
18F-FDG-PET to be accurate in the identification
of extra-hepatic disease. In a meta-analysis, PET/
CT had a sensitivity of 91.2 per cent and a specifi-
city of 95.4 per cent in identifying extra-hepatic
metastases.63
As a result of this high sensitivity for meta-
static disease in rectal cancer, 18F-FDG-PET
has been used in the preoperative assessment of
patients being considered for resection of hepatic
metastases. A number of studies have shown that
18F-FDG-PET significantly alters management in
patients being considered for metastasectomy, pre-
dominantly by identifying additional extra-hepatic
metastases in 10–21 per cent of patients,64,65 and so
reduces the rate of negative laparotomies due to
unexpected metastatic disease at the time of surgery
by approximately 9 per cent.63 The identification of
lung metastases may also allow successful resection
of both lung and liver metastases.
18F-Fluorodeoxyglucose positron-emission tom-
ography has also been used to identify pelvic recur-
rence in rectal cancer. Following surgery, scarring and
fibrosis can be difficult to distinguish from recurrence
on anatomical imaging, and this problem can be
compounded by post-radiotherapy changes. A meta-
analysis suggested that the sensitivity and specificity of
18F-FDG-PET in detecting pelvic recurrence in rectal
cancer are both 94 per cent.66
18F-Fluorodeoxyglucose positron-emission tomo-
graphy is also used widely to help identify metastatic
HEBK001-C05_p71-86.indd 77
disease in the presence of normal or equivocal ana-
tomical imaging and endoscopy and a high index of
suspicion of recurrent rectal cancer, for example in
the presence of rising CEA. In these circumstanc-
es, Flamen and colleagues found that 18F-FDG-
PET had a per-lesion sensitivity of 75 per cent,67
although it should be noted that in this study 38 per
cent of patients had equivocal findings on conven-
tional imaging and 70 per cent had not undergone
chest CT.
Despite the apparent superiority of systemic stag-
ing incorporating 18F-FDG-PET, very few stud-
ies have looked at the impact of 18F-FDG-PET on
the primary staging of rectal cancer. Heriot and
colleagues assessed this issue in 46 patients with
advanced primary rectal cancer and found that man-
agement was changed in 17 per cent of patients,68
although again it should be noted that patients did
not undergo routine preoperative thoracic CT.
There are a number of potential limitations in
18F-FDG-PET staging of rectal cancer. Establishing
the precise anatomical location of increased FDG
uptake may be difficult, and because of this it is not
always possible to identify the anatomical location of
liver metastases using 18F-FDG-PET. Physiological or
benign increased FDG uptake may create false posi-
tives, such as granulomatous and inflammatory proc-
esses in the lung. Following radiotherapy, granulation
tissue, fibroblast and macrophage activity may give
false positives. This is a particular problem in the first
6 months following radiotherapy. The spatial reso-
lution of 18F-FDG-PET is limited to around 7 mm,
which means that lesions need to be about 1 cm or
larger in size to be identified. This particularly limits
the ability of 18F-FDG-PET to identify small-volume
peritoneal and liver surface disease.
Some authors have suggested that the incidence
of extra-hepatic metastases in patients with a low
clinical risk score being considered for hepatic
metastasectomy is so low that 18F-FDG-PET is
of limited value. Indeed, in this group of patients,
the use of 18F-FDG-PET may incorrectly upstage
patients and prevent them from undergoing poten-
tially curative resection.69
To reduce the risk of false positives and false
negatives in 18F-FDG-PET imaging, interpretation
with correct anatomical information from cross-
sectional imaging is very important. For this rea-
son, combined 18F-FDG-PET/CT has superseded
18F-FDG-PET in many situations.
08/02/13 5:59 PM
 78  Radiological staging for systemic disease

Combined 18F-Fluorodeoxyglucose
Positron-Emission Tomography and
Computed Tomography
Combining CT and 18F-FDG-PET in the same scan-
ner allows attenuation correction for the PET por-
tion of the imaging, but also allows fusion of the
anatomical component of the CT scanning with the
functional element of the 18F-FDG-PET. The risk of
misregistration of PET and CT images is reduced (but
not eliminated) by combining both types of imaging
in the same machine at the same time. It is hoped that
this combined functional and anatomical imaging will
be more accurate in the identification of rectal cancer
metastases than either imaging modality alone.70
Niekel and colleagues noted in a meta-analysis
that there were not enough studies of 18F-FDG-
PET/CT in the detection of liver metastases to Figure 5.7. Combined 18F-fluorodeoxyglucose positron-
comment on its accuracy.61 In a single series of emission tomography and computed tomography
467 patients, however, Orlacchio and colleagues demonstrating internal iliac lymph node metastasis
have suggested that the combined 18F-FDG-PET/ (arrowhead).
CT modality is more accurate than either modality
alone in identifying colorectal liver metastases, with Davey and colleagues assessed the impact of
reported per-patient sensitivity and specificity of 18F-FDG-PET/CT on the management of 83
98 per cent.71 An 18F-FDG-PET/CT scan demon- patients with primary rectal cancer and found that
strating liver metastases is illustrated in Figure 5.6, management was altered in 12 per cent.72
outlining lymph node metastases in Figure 5.7, and
bilateral ovarian metastases in Figure 5.8.

Figure 5.8. Combined 18F-fluorodeoxyglucose positron-

emission tomography (FDG) and computed tomography
Figure 5.6. Combined 18F-fluorodeoxyglucose positron- demonstrating bilateral ovarian metastases (white
emission tomography and computed tomography arrowheads). Physiological FDG uptake is seen in the right
demonstrating liver metastases (arrowheads). ureter (black arrowhead).

HEBK001-C05_p71-86.indd 78 08/02/13 5:59 PM

 IMAGING MODALITIES AVAILABLE FOR STAGING SYSTEMIC DISEASE  79

Pelvic Magnetic Resonance Imaging

As discussed in Chapter 4, pelvic MRI is used pre-

dominantly for the local staging of rectal cancer
and is very accurate for this purpose. In some
instances, however, pelvic MRI may also demon-
strate systemic disease in rectal cancer. Ovarian
metastases may be evident on pelvic MRI; they
most commonly take the form of solid adnexal
masses with intratumoural cysts, although they
may also be predominantly solid or predominant-
ly cystic lesions.50 Figure 5.9 shows a typical ovar-
ian metastasis on MRI.
Lymph node metastases may also be identified
on pelvic MRI. Lymph node metastases occur-
ring within the mesorectal envelope will usually
be removed at the time of optimal total mesorectal
excision surgery and so can be considered with the Figure 5.10. Magnetic resonance imaging demonstrating
local staging. Distant lymph node metastases may internal iliac lymph node metastasis (arrowhead).
also be identified along the internal iliac chain or
less commonly in the inguinal lymph node groups, Peritoneal disease may also be detected and on
however. Although overlap between benign and T2-weighted MRI has an intermediate signal inten-
malignant lymph nodes makes size criteria unre- sity, which appears relatively hyperintense com-
liable, morphological changes such as an irregular pared with the low-signal peritoneum. Figure 5.11
border or inhomogeneous signal intensity have a illustrates peritoneal disease on T2-weighted MRI.
high positive predictive value, and lymph nodes If peritoneal disease is suspected, fat-suppressed
demonstrating these characteristics should be treat- T1-weighted imaging with gadolinium enhance-
ed as metastatic disease.73 Figure 5.10 illustrates a ment may be of benefit in highlighting mesenteric
typical lymph node metastasis identified on MRI. deposits.74

Figure 5.9. Magnetic resonance imaging demonstrating Figure 5.11. Magnetic resonance imaging demonstrating
bilateral ovarian metastases (arrowheads). peritoneal metastases (arrowhead).

HEBK001-C05_p71-86.indd 79 08/02/13 5:59 PM

 80  Radiological staging for systemic disease
Hepatic Magnetic Resonance Imaging
Dedicated liver MRI is a highly accurate modality for
identifying colorectal metastases to the liver. A meta-
analysis of CT, MRI and PET/CT found that on a per-
lesion basis, for lesions over 1 cm in size, MRI was the
most sensitive modality for identifying colorectal liver
metastases.62 This study also found that gadolinium-
enhanced and SPIO-enhanced MRI was significantly
more accurate than unenhanced MRI. A more recent
meta-analysis, which included only prospective stud-
ies, found that on a per-lesion basis, CT, MRI and
18F-FDG-PET had comparable sensitivity of 74.4 per
cent, 80.3 per cent and 81.4 per cent. The sensitivity of
MRI had increased since 2004, however, and in studies
since 2004 the sensitivity of MRI on a per-lesion basis
is 84.9 per cent; MRI is also the most accurate modali-
ty in identifying lesions less than 10 mm in diameter.61
A paper comparing liver specific contrast-enhanced
MRI and 18F-FDG-PET/CT suggested that on a per-
patient basis PET/CT and MRI had equally high sen-
sitivity and specificity at 98 per cent and 100 per cent,
respectively, but on a per-lesion basis for lesions less
than 1 cm MRI was more sensitive.75
The mainstay of liver MRI is the T1-weighted
gradient echo sequence. This allows imaging of
the whole liver in a single breath-hold, reduc-
ing motion artefact. T1-weighted gradient echo
sequences can also be acquired as a volume image
and reconstructed in any plane, allowing accurate
anatomical localization of lesions. Figure 5.12 illus-
trates hepatic metastases on a T1-weighted MRI.
Figure 5.12. Comparison of gadoxetic acid-enhanced magnetic resonance imaging (MRI) and unenhanced T1-weighted
MRI. Gadoxetic acid MRI (left) shows liver metastases (black arrowhead) not seen on unenhanced T1-weighted MRI.
Second metastasis (white arrowhead) is seen on both gadoxetic acid-enhanced and unenhanced MRI.
HEBK001-C05_p71-86.indd 80
Additional sequences are useful to help with
lesion characterization and thus help to determine
whether lesions represent colorectal liver metastas-
es. In-phase and out-of-phase T1-weighted imaging
may help assess areas of focal fatty infiltration, which
may appear as apparent ‘perfusion defects’ on CT
and mimic colorectal liver metastases. T2-weighted
images, which may be acquired as either respiratory-
triggered fast spin echo (FSE) sequences or breath-
hold single-shot FSE ­sequences, further help with
the characterization of focal liver lesions.
A number of different contrast agents have been
used to increase the sensitivity and specificity of
liver MRI. Dynamic gadolinium contrast enhance-
ment can be obtained with images in arterial, por-
tal venous, equilibrium and delayed phases. This is
superior to dual-phase contrast-enhanced spiral CT,
especially in lesion characterization.76 Superpara-
magnetic iron oxide may also increase sensitivity and
specificity of liver MRI in detecting colorectal liver
metastases. Superparamagnetic iron oxide is taken
up by Kupffer cells, rendering the substance of liver
dark on T1 gradient echo sequences. Liver metastases
without functioning Kupffer cells therefore appear
relatively hyperintense. Other lesions including cysts
and cavernous haemangiomas may also be relatively
hyperintense, and so images must be interpreted with
T2-weighted images to avoid false positives.77 The
American Food and Drug Administration has not
approved SPIO contrast agents, however, and in 2011
all previously available SPIO preparations were with-
drawn from the market.
08/02/13 5:59 PM
 IMAGING MODALITIES AVAILABLE FOR STAGING SYSTEMIC DISEASE  81

Figure 5.13. Comparison of gadoxetic acid-enhanced magnetic resonance imaging (MRI) and contrast-enhanced
computed tomography. Gadoxetic acid MRI (left) shows liver metastasis (arrowhead) not seen on contrast-enhanced CT.

Liver-specific gadolinium-based contrast agents
such as gadoxetic acid and gadobenate dimeglu-
min are taken up by functioning hepatocytes. This
causes increased signal in the liver parenchyma
on T1-weighted images. Metastatic lesions remain
hypointense. These liver-specific contrast agents
increase the sensitivity of liver MRI for colorectal
liver metastases, particularly for small lesions.78
Figure 5.13 illustrates colorectal liver metastases on
gadoxetic acid-enhanced MRI.
Diffusion-weighted imaging (DWI) is an MRI
technique that identifies areas within tissues with
restricted diffusion. As many tumours contain tight-
ly packed cells with a poorly organized extracellular
matrix, they frequently have restricted diffusion of
water molecules compared with normal tissues. This
has been exploited in hepatic MRI to help identify
and characterize metastatic lesions within the liver.
Although evidence is still accumulating for this tech-
nique, a number of studies have suggested that the
addition of DWI sequences to standard liver MRI
protocols can increase the sensitivity.79,80 Figure 5.14
illustrates colorectal liver metastases on DWI.
Transabdominal Ultrasound
The primary use of ultrasound in the systemic stag-
ing of rectal cancer has been to evaluate the liver
for the presence of metastases. Liver metastases may
lack contrast with the surrounding normal tissue,
however, and therefore may be difficult to identify

Figure 5.14. Diffusion-weighted imaging (DWI) and corresponding gadolinium-enhanced magnetic resonance imaging.
Metastasis (white arrowheads) demonstrates restricted diffusion of DWI.

HEBK001-C05_p71-86.indd 81 08/02/13 5:59 PM

 82  Radiological staging for systemic disease
on ultrasound. A meta-analysis found that the sen-
sitivity of ultrasound on a per-patient basis for
identifying liver metastases was 55 per cent, com-
pared with 72 per cent for CT, 75 per cent for MRI
and 90 per cent for 18F-FDG-PET.81
Micro-bubble contrast agents have been used to
improve the ability of ultrasound to identify liver
metastases and detect around 17 per cent more lesions
than conventional B-mode non-contrast-enhanced
ultrasound.82 Even when using micro-bubble contrast
agents, however, ultrasound is still less sensitive than
CT in detecting liver metastases.83 It also does not offer
the opportunity to identify metastases at other sites.
Ultrasound is cheap and widely available. There-
fore, ultrasound may still have a role as a screening
or monitoring technique in some institutions and
occasionally helps to clarify the nature of a hepatic
abnormality. Computed tomography, PET and
MRI are superior imaging modalities where these
facilities are available, however.
Intraoperative Ultrasound
Intraoperative ultrasound is used in many institutions
for the intraoperative assessment of patients under-
going resection of hepatic metastases. In this setting,
ultrasound is helpful; it alters surgery in 20–44 per cent
of patients and demonstrates anatomy relative to the
metastases to help plan resection.84,85 It is ­particularly
useful in the intraoperative setting to detect small
lesions for resection or radiofrequency ablation that
may otherwise have been missed.86
Laparoscopy
In certain circumstances, diagnostic laparoscopy
with cytology or histology may be useful to assess
the presence of metastatic disease if non-invasive
investigations are equivocal. The steady improve-
ment in non-invasive cross-sectional and func-
tional imaging will probably continue to reduce the
situations where laparoscopy is necessary, however.
Chest X-ray
Chest radiography is less sensitive and specific in
detecting colorectal liver metastases than thoracic
HEBK001-C05_p71-86.indd 82
CT. In a study of 1049 patients who underwent chest
X-ray for the purposes of preoperative colorectal
cancer staging, only 0.86 per cent of patients had
lung metastases correctly identified.87 Chest radi-
ography should therefore be reserved for situations
where thoracic CT is not available.
Assessing response
to chemotherapy
Aside from identifying metastatic disease, imaging
also has an important role to play in the assessment
of response to treatment and in restaging disease
following chemotherapy.
The accuracy of 18F-FDG-PET in assessing met-
astatic disease appears to be reduced in the period
immediately following chemotherapy. In a study of
138 patients investigating the accuracy of PET in
identifying colorectal liver metastases, Glazer and
colleagues found that PET had a negative predic-
tive value of only 13.3 per cent when performed
within 4 weeks of chemotherapy.88 This is probably
due to the metabolic inhibition of chemotherapeu-
tic agents preventing metastatic lesions from taking
up FDG, despite harbouring viable tumour cells.
Other studies have supported this finding, report-
ing a per-lesion sensitivity of PET of only 47–62
per cent,89,90 and a per-patient sensitivity of 63 per
cent,91 after chemotherapy.
The accuracy of anatomical imaging per-
formed following chemotherapy appears to be
comparable to the accuracy in the absence of
chemotherapy. Superparamagnetic iron oxide-
enhanced MRI has a per-lesion sensitivity of 92
per cent following chemotherapy,89 and non-con-
trast MRI has a per-lesion sensitivity of 80 per
cent.92 Contrast-enhanced CT has a per-lesion
sensitivity of 65–76 per cent.90–92
The response of colorectal cancer metastases to
treatment is therefore best assessed using anatomi-
cal imaging on either serial CT or MRI scans. An
objective assessment of response can be obtained
by repeated measurements of identified lesions;
the Response Evaluation Criteria In Solid Tumors
(RECIST) guidelines provide a structure for con-
sistent assessment.93
Restaging of hepatic metastases following neoadju-
vant chemotherapy before resection is best performed
using MRI with a liver-specific contrast agent.
08/02/13 5:59 PM

Future developments
Incremental improvements in both MRI and CT
technology have steadily increased the speed and
spatial resolution of these imaging modalities, and
it is likely that similar advances will see the spa-
tial and perhaps contrast resolution of anatomical
imaging continue to increase.
Functional imaging, and in particular fused
functional and anatomical imaging, has undergone
rapid development. Alternative radiotracers such as
39-deoxy-39-[18F]fluorothymidine (FLT) are being
investigated, and it is possible that more specific
tracers will improve the specificity of PET in the
future. It is also likely that the spatial resolution of
PET will continue to increase, and this may further
increase the sensitivity of PET in the future.
Technological hurdles have been overcome to
allow PET and MRI scanning to be incorporated
in the same machine as PET/MRI fusion. Ongoing
research is under way to determine whether this
offers an advantage over current PET/CT.
CONCLUSION
The ideal modality for systemic staging of rectal
cancer would be cheap, be widely available, have
a high sensitivity for identifying rectal metastases
in all sites, and have a high specificity. Unfortu-
nately, no modality currently fulfils all these crite-
ria. It is therefore necessary to use a multimodality
approach and to adapt the staging strategy to the
patient’s situation to try to maximize the benefit
from available imaging resources.
Computed tomography of the chest, abdomen
and pelvis is a good baseline investigation for the
primary systemic staging of rectal cancer. It identi-
fies metastatic disease with good sensitivity in the
most commonly affected sites and should be per-
formed in all patients where this facility is available.
Review of serial CT images increases the sensitiv-
ity and specificity of subsequent CT for identifying
recurrent and metastatic disease in the follow-up
period.
Magnetic resonance imaging should be used
to clarify the nature of indeterminate liver lesions
identified on baseline or follow-up CT. Liver MRI
should also be performed in patients being consid-
ered for resection of liver metastases, as this probably
HEBK001-C05_p71-86.indd 83
References  83
provides the most accurate per-lesion preoperative
assessment of liver disease.
18F-Fluorodeoxyglucose positron-emission tom-
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investigation for patients with a high index of clinical
suspicion for metastatic disease (such as rising CEA)
and normal first-line investigations. It may also be of
benefit in assessing pelvic recurrence and in excluding
extra-pulmonary and extra-hepatic disease in patients
being considered for metastasectomy.
Further studies are required to define the role of
modalities other than CT in the primary systemic
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In the future, functional imaging may help in selec-
tion of patients most likely to benefit from neoadju-
vant therapy before surgery and in determining the
likelihood and presence of a complete pathological
response and thus selecting patients in whom sur-
gery can be deferred and occasionally avoided.
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HEBK001-C05_p71-86.indd 85
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08/02/13 5:59 PM

Preoperative radiotherapy and
chemoradiotherapy for rectal cancer
Rob Glynne-Jones and Mark Harrison
Introduction
Colorectal cancer is one of the most common solid
tumours, of which approximately 40 per cent of
patients have rectal cancer. Historically, surgery
alone for rectal cancer has been associated with a
high incidence of local recurrence. Additionally,
some 10–40 per cent of patients with rectal cancer
require extirpative procedures leading to a perma-
nent stoma. A landmark retrospective study high-
lighted the poor prognosis for patients with rec-
tal cancer, with a 5-year survival of 6 per cent in
patients with pathologically Dukes C cancer.1
In the light of these results, using post-surgical
histology to define risk, several postoperative stud-
ies investigated chemotherapy and radiotherapy2
or a combination of both to prevent local recur-
rence and reduce metastases. Overall, these studies
showed a significant benefit for the combination
of chemoradiation.3,4 Interestingly, a retrospective
analysis of pooled data from US trials showed simi-
lar 5-year overall survival for patients with pT3N0
rectal cancer treated with either surgery or chemo-
therapy alone (84 per cent) compared with those
treated with postoperative chemoradiotherapy
(74–80 per cent).5 Similar data have been reported
from the National Cancer Data Base.6
With the introduction of better preoperative
imaging such as computed tomography (CT),
HEBK001-C06_p87-102.indd 87
6
ultrasound and magnetic resonance imaging
(MRI) to stage patients, the success of postoperative
chemoradiation was extrapolated to the preopera-
tive setting. The concept of spatial cooperation in
preoperative chemoradiation for locally advanced
rectal cancer is attractive.7 Chemotherapy may, as
a component of chemoradiation, act as a radio-
sensitizing agent; it may also potentially eradicate
distant micro-metastases. In general, concurrent
chemotherapy has proved more effective than the
sequential use of these modalities.8
A series of randomized controlled trials have
clearly shown the superiority of preoperative radia-
tion or chemoradiation therapy compared with
postoperative treatment.9–13 Current recommenda-
tions suggest the use of preoperative chemoradiation
followed by total mesorectal excision (TME) surgery
as the standard treatment of choice for the majority
of patients diagnosed with advanced rectal cancer.
In the past two decades, greater understanding
of the natural history of the disease and patterns
of recurrence, and more precise histopathological
reporting, have helped to define patients with a high
risk of local recurrence and metastatic disease fol-
lowing ‘curative resection’.14 This particular focus
on the circumferential resection margin (CRM) has
driven technical advances in surgical technique with
meticulous surgical dissection along ­embryological
planes and highlighted the ­importance of
08/02/13 5:58 PM
 88  Preoperative radiotherapy and chemoradiotherapy for rectal cancer
­ reoperative assessment of the tumour with MRI.
p More recently, a number of molecularly targeted
Even technically optimized surgery is unlikely to
achieve a curative resection when the preoperative
MRI shows a threatened or breached CRM. In addi-
tion, at the time of diagnosis, some 20–25 per cent
of patients with rectal cancer are found to have overt
metastatic disease, and a further 30–40 per cent sub-
sequently develop metastases.
The multimodality treatment of rectal cancer
attempts to integrate the three modalities of sur-
gery, radiotherapy and chemotherapy as strategies
to eradicate cells at the margins or in discontinuous
areas of tumour within the pelvis, in lymph nodes
or in distant metastatic sites to improve both local
control and overall survival.
Systematic reviews and several meta-analyses
have examined the role of radiotherapy (as opposed
to chemoradiation) in resectable rectal cancer.15–17
These meta-analyses concluded that the evidence
from relevant trials favoured preoperative rather
than postoperative radiotherapy, and that a bio-
logically equivalent dose greater than 30 Gy is more
effective in reducing local relapse. A 2007 Cochrane
review further supports these findings but failed to
confirm a reduction in mortality or any advantage
in terms of sphincter sparing from preoperative
radiotherapy.18 The Cochrane review also high-
lighted the significant risks of increased pelvic and
perineal infections when radiation and surgery are
combined, and a detriment to the patient’s anorec-
tal, urinary and sexual function.
Since the early 1980s, the fluoropyrimidine
5-fluorouracil (5FU) alone, and more recently in
combinations of cytotoxic chemotherapy using
oxaliplatin or irinotecan, has represented the main-
stay of chemotherapy treatment for patients with
advanced and metastatic colorectal cancer. These
combinations have been integrated into chemora-
diation regimens and tested in a number of prospec-
tive randomized trials in rectal cancer, potentially to
mirror the success of 5FU and oxaliplatin in deal-
ing with distant micro-metastases in the adjuvant
setting in colon cancer.19–21 Investigators have used
these cytotoxic agents either as ­radiosensitizers22,23 or
in an attempt to use systemically active chemother-
apy preoperatively with an appropriate duration.24–26
Perhaps surprisingly when used as a radiosensitizer,
these combinations of a cytotoxic agent and radia-
tion have had only moderate success in improving
outcome in rectal cancer.12,13,22,23,27
HEBK001-C06_p87-102.indd 88
agents have been integrated into standard palliative
chemotherapy regimens for advanced metastatic
colorectal cancer. These biologically targeted agents
appear to improve response rates and extend pro-
gression-free and overall survival, albeit with varying
success.28–31 Three monoclonal antibodies have now
entered clinical practice in colorectal cancer – cetuxi-
mab, panitumumab and bevacizumab. A strategy
to incorporate these newer biologically active tar-
geted agents into chemoradiation schedules has also
emerged.
In this chapter, we examine the rationale for pre-
operative radiation and chemoradiation, the selec-
tion of patients who are appropriate for long-course
preoperative radiotherapy and short-course preop-
erative radiation (SCPRT), the techniques available
such as intensity-modulated radiotherapy (IMRT),
optimal doses and field size, the integration of cyto-
toxic chemotherapy and biological agents, potential
biological markers, and future potential strategies
of treatment.
Defining the most
appropriate treatment
strategy
The terms ‘favourable’, ‘early’ and ‘good’, ‘intermedi-
ate’ and ‘bad’, and ‘locally advanced’ and ‘ugly’ have
historically been used for categorizing rectal cancer
into clinical subgroups. The term ‘locally advanced’
has been commonly used in a very broad and unde-
fined way and generally directed the patient to
receive preoperative treatment. In the 1980s, preop-
erative assessment and clinical staging of rectal can-
cer was limited to digital rectal examination, pos-
sibly a rigid sigmoidoscopy and a barium enema. A
clinical judgement based on these findings assessed
tumour fixity, but there was no widely accepted and
validated imaging method of defining either locally
advanced rectal cancer or unresectable disease.
Currently, we broadly consider patients to have
easily resectable cancers (which can be cured by
radical surgery alone), borderline resectable dis-
ease (i.e. a potentially ‘threatened’ or minimally
breached circumferential margin as predicted by
MRI), or unresectable cancers with disease outside
the mesorectum (for whom surgery is not possible
without leaving tumour within the pelvis).
08/02/13 5:58 PM

Our increased level of knowledge is based on the
use of preoperative MRI, which allows division of
rectal cancers into categories with different risks
and different indications for preoperative radio-
therapy. Preoperative treatment may be tailored
to the radiological stage of the tumour to facilitate
a reduction of risk of local recurrence, improved
likelihood of curative resection, or identification of
unresectable disease and prevention of an unneces-
sary surgical procedure. Use of MRI allows rectal
cancer to be divided into the following groups:
1. very early (some cT1 sm1/2)
2. low risk (.cT1 sm2 to cT2, some cT3a (to T3c),
CRM 2 /N0)
3. locally advanced (cT3, some T4 crm 2 /N1)
4. potentially unresectable advanced (cT3 CRM1
or cT4)
5. unresectable disease (extension to lateral
pelvic side-wall/lateral pelvic lymph node
involvement/disease outside the pelvis).
Other well-recognized factors such as tumour
height, proximity to the CRM, cN stage, lymphovas-
cular invasion, extramural vascular invasion and
perineural invasion are also relevant to the risk of
local recurrence and the development of metastat-
ic disease. Where possible, these factors should be
mentioned in the MRI report with the proviso that
they are categorized with the prefix ‘mr’, e.g. mrN1
or mrEMVI. The relevance of the historical clinical
classification into fixed, tethered or mobile tumours
is unclear if MRI is performed for decision-making,
but it may be complementary, especially in low rectal
tumours. In all patients, a history, clinical examina-
tion and rectal examination by the responsible sur-
geon is mandatory, and the surgical opinion on cur-
rent and likely future anorectal function should be
transmitted to the radiation oncologist, ideally at the
multidisciplinary team colorectal conference.
PREOPERATIVE RADIOTHERAPY
There are a number of theoretical advantages of
preoperative radiation therapy compared with
postoperative radiation therapy. To an extent, these
advantages have been confirmed in clinical trials:
l Preoperative radiation can be delivered to an
area where the blood supply has not yet been
HEBK001-C06_p87-102.indd 89
PREOPERATIVE RADIOTHERAPY  89
compromised by surgery and infection; theo-
retically, better oxygenation will improve the
radiosensitivity of the tumour cells.
l An R0 resection is much more likely if the
tumour undergoes a degree of shrinkage.
l Killing or sterilizing all the tumour cells with
radiation before surgery may reduce the risk
of tumour cells seeding in the wound during
surgery, particularly in the posterior pelvis
when the patient lies supine, thereby decreasing
the local recurrence rate.
l With preoperative treatment, the tumour, drain-
ing lymph nodes and adjacent mesorectum can
be targeted in the gross tumour volume and
clinical target volume, rather than an uninvolved
length of bowel and mesocolon, which may
already have a compromised blood supply.
l The clinical target volume will not be required
to cover the perineum, and there will be no
radiation to the anastomotic site.
l The small bowel is much less likely to be includ-
ed in the radiation field, unless the patient has
had a hysterectomy or previous pelvic surgery.
l Although still unvalidated, the preoperative
approach may define good and bad prognos-
tic groups of patients by their response to
­treatment.32–36
For all these reasons, the expectation is that the
acute and late toxicity of preoperative radiation will
be less, and hence compliance will be better and
more patients will receive the full dose of radiation.
Three adjuvant radiation approaches have been
in common use: SCPRT, long-course preoperative
radiation and long-course preoperative chemoradi-
ation. Long-course radiation alone has been shown
to be less effective in terms of local control when
compared with preoperative 5FU-based chemora-
diation27,37 and hence is used only in patients who
are unfit for chemotherapy; it will be discussed only
briefly here.
There are different rationales for SCPRT and
chemoradiotherapy, and some differences in
tumour target volume definition that will be dis-
cussed later. Short-course preoperative radio-
therapy uses a short intensive course of radiation
delivered with a dose of 25 Gy over 5 days. The sin-
gle aim of treatment is to reduce the risk of pelvic
recurrence. This approach has gained widespread
acceptance in Europe following the publication of
08/02/13 5:58 PM
 90  Preoperative radiotherapy and chemoradiotherapy for rectal cancer
the ­Swedish and Dutch rectal cancer studies.38,39 In
contrast, the rationale for preoperative chemoradi-
otherapy is more attractive, as it combines early sys-
temic chemotherapy with a locoregional treatment.
Current criteria in our own units for the delivery
of preoperative chemoradiation rely on MRI scan-
ning in determining the extent of tumour either at
(i.e. within 1 mm) or outside the mesorectal enve-
lope or below the envelope extending into the leva-
tors and sphincter mechanism. Using these MRI
criteria, it is possible to predict patients in whom
there is a high risk that the surgeon will not be able
to perform an R0 resection and will leave gross
macroscopic or undetected microscopic tumour
behind in the pelvis.
Rendering unresectable
tumours resectable
A minority of patients present with a rectal tumour
that cannot be resected without leaving residual
macroscopic or microscopic disease. The multimo-
dality approach to rectal cancer management allows
these patients to be identified before an (unsuc-
cessful) attempt at surgical resection is made. This
approach facilitates the use of preoperative radio-
therapy or chemoradiotherapy.
Before the development of pelvic MRI, most
patients were identified by the presence of tumour
fixity determined either in the clinic or during an
examination under anaesthetic. Pragmatically this
method of assessment is limited to those tumours
where the examining finger can assess mobility of
the tumour. Pelvic MRI can assist in demonstrat-
ing the relationship of the primary tumour to the
surrounding mesorectal fascia and the surrounding
organs, as well as enlarged lymph nodes with MRI
appearances of tumour involvement. Thus, patients
may be selected for preoperative radiation in this
category if there is evidence of primary tumour
involving or extending beyond the mesorectal fas-
cia; primary tumour within 1–2 mm of the mes-
orectal fascia; involved lymph nodes outside the
mesorectal fascia (usually iliac nodes); and primary
tumour involving the levators. Since response and
shrinkage of the tumour is required, these patients
require preoperative chemoradiotherapy. Current
approaches use a fluoropyrimidine combined with
radiation, although many phase II studies of the use
HEBK001-C06_p87-102.indd 90
of combination chemotherapy schedules have been
completed or are ongoing.
Two randomized trials in unresectable disease
have confirmed an advantage for 5FU-based chem-
oradiation over radiation alone.40 One very small
phase III trial in unresectable rectal cancer com-
pared radiation alone with chemoradiotherapy in
Sweden, demonstrating improved resectability and
local control with the use of chemoradiotherapy.41
Reducing local recurrence
The majority of randomized trials in rectal cancer
have been performed in patients with resectable rec-
tal cancer, where the aim of treatment has been to
lower the risk of local recurrence. Some of these trials
were performed before 2000 prior to the acceptance
of the benefits of meticulous surgical dissection in
the form of mesorectal excision. The local recurrence
rates in the surgery alone arm of these studies were in
the range of 21–36.5 per cent.16
Three retrospective systematic reviews/meta-anal-
yses have been published on the role of radiotherapy
in rectal cancer.15–17 The Colorectal Cancer Collabo-
rative Group meta-analysis identified 22 randomized
controlled trials that have compared the use of both
preoperative radiotherapy (14 trials, 6350 patients)
and postoperative radiotherapy (8 trials, 2157
patients) in patients intended to undergo a curative
resection for rectal cancer, versus surgery alone.16
In the entire group of patients, overall survival at
5 years was not significantly different, with a 5-year
overall survival of 45 per cent in the patients receiv-
ing radiation versus 42.1 per cent in the patients
treated with surgery alone. Despite the lack of effect
on overall survival, there was an expected reduction
in local recurrence. In the preoperative trials, the
rate of local recurrence at 5 years was 12.5 per cent
in the patients treated with radiation versus 22.2
per cent in the patients treated with surgery alone.
Postoperative radiation also reduced the rate of
local recurrence from 23.8 per cent in the patients
treated with surgery alone to 16.9 per cent in the
patients receiving radiation.
Trials performed in individual countries have
influenced their definition of the ‘standard of care.’ A
German phase III trial reported improved outcome
for preoperative chemoradiotherapy in this setting.
A total of 823 patients were randomized between
08/02/13 5:58 PM
 LONG-COURSE PREOPERATIVE 5-FLUOROURACIL-BASED CHEMORADIOTHERAPY  91
preoperative chemoradiotherapy and postopera-
tive chemoradiotherapy (patients received postop-
erative adjuvant chemotherapy in both arms of the
trial). Local recurrence and acute and late toxicity
were statistically significantly reduced with the pre-
operative approach, but there was no difference in
the distant metastases rate or overall survival.12
In contrast to the German approach, a short
accelerated preoperative radiation schedule of
25 Gy in five fractions (SCPRT) with surgery per-
formed within a few days of completion of radia-
tion was developed in Sweden to reduce the risk of
local recurrence. The Swedish Rectal Cancer Trial
demonstrated a significant reduction in local recur-
rence and a 10 per cent absolute improvement in
survival; this led to the widespread adoption of
SCPRT in the Scandinavian and northern Euro-
pean countries.38
The Swedish Rectal Cancer Trial is the only major
modern trial to show a benefit in survival from pre-
operative radiotherapy. This trial randomized 1168
patients with resectable rectal cancer to SCPRT fol-
lowed by surgery, versus surgery alone. The radia-
tion was delivered over 5 days with 5 Gy per frac-
tion. The 5-year overall survival was significantly
better in the radiation–surgery group (58 per cent)
than in the surgery-only group (48 per cent) (P 5
0.004). The benefit of radiation persisted through a
median of 13 years’ follow-up (38 per cent alive v.
30 per cent, P 5 0.008). Local recurrence as either
a first or later event was less common in the group
of patients treated with radiation (9 per cent v. 26
per cent, P , 0.001).42 The survival advantage seen
in this trial has been suggested to derive from the
large difference in local recurrence rates between
the two groups, which may have been a reflection of
the suboptimal surgery before the TME era.
The Dutch Colorectal Cancer Group conducted
a large, prospective, randomized trial using an iden-
tical radiation schedule to that used in the Swed-
ish Rectal Cancer Trial. In the Dutch trial a series
of surgical training programmes and mentoring
attempted to standardize the surgical procedure,
and all patients underwent surgery by TME prin-
ciples. Of 1805 eligible patients, 897 were rand-
omized to radiation and then immediate surgery
(within 1 week of completion) and 908 were ran-
domized to surgery alone. The overall survival
at 5 years was similar in the two groups: 64.2 per
cent in the preoperative radiation group compared
HEBK001-C06_p87-102.indd 91
with 63.5 per cent in the surgery-only group. Local
recurrence at 5 years was 5.6 per cent and 10.9 per
cent, respectively (P , 0.001). The low level of local
recurrence rate in this trial has led to the acceptance
of TME as the standard surgical technique. Mature
outcome from the trial has confirmed a reduction
in local recurrence but no survival benefit.43
In the UK, some colorectal multidisciplinary
teams have adopted the non-selective use of rou-
tine SCPRT, while others use pelvic MRI to deter-
mine patients whose primary tumour is predicted
to be clear of the CRM and in whom initial surgery
is performed. The Dutch and Medical Research
Council (MRC) CR07 trials have directly compared
these two approaches. The Dutch trial examined
the routine use of SCPRT followed by TME, with
TME and selective postoperative radiotherapy in
the event of histopathological evidence of involve-
ment of the circumferential resection margin.
The Dutch trial appears to show an absolute
reduction in local recurrence of 6 per cent. Thus,
if 100 patients are irradiated, 6 local recurrences
are prevented, i.e. the number of patients needed
to treat to prevent 1 local recurrence is 16.7. In the
MRC CR07 trial, if a good mesorectal excision was
performed,44 the number needed to treat appears to
be over 20. As stated above, the present authors do
not therefore support the widespread advocacy for
routine adjuvant radiotherapy as used in the treat-
ment arms of recent trials.
There is increasing evidence that patients with
very low tumours that require abdominoperineal
excision are at higher risk of involvement of the
CRM, local recurrence and inferior survival. Most
agree that routine preoperative radiotherapy is
indicated for this group of patients. It is a source of
considerable debate whether SCPRT may be used
in some patients, whether chemoradiotherapy is
preferred in other patients, and whether a wider
cylindrical surgical technique should be adopted to
reduce the rate of an involved CRM.
LONG-COURSE PREOPERATIVE
5-FLUOROURACIL-BASED
CHEMORADIOTHERAPY –
45–50 GY IN 5 WEEKS
Randomized studies in resectable T3/T4 rectal can-
cers have compared preoperative chemoradiation
08/02/13 5:58 PM
 92  Preoperative radiotherapy and chemoradiotherapy for rectal cancer
(45 Gy in 25 fractions over 5 weeks) and 5FU-based
chemotherapy with radiation alone.27,37 Surgery is
undertaken 4–12 weeks following chemoradio-
therapy to allow the patient to recover and enable
tumour shrinkage. The addition of 5FU to preoper-
ative radiation increases the pathological complete
response rate over radiotherapy alone and provides
evidence for improvements in locoregional control
but has not translated into an improvement in dis-
ease-free survival or overall survival.
Trials in unresectable disease have also confirmed
an advantage for chemoradiation over radiation
alone.40 Local control was significantly better (82
per cent v. 67 per cent at 5 years, P 5 0.03), with
a trend towards improved overall survival (66 per
cent v. 53 per cent at 5 years, P 5 0.09).
Oral Alternatives to 5-Fluorouracil
In the neoadjuvant setting in rectal cancer, the safety
and efficacy of capecitabine45 and a combination of
uracil and tegafur46 have been compared with that
of a continuous intravenous infusion (CVI) of 5FU.
For capecitabine, the authors used data from 345
patients treated with capecitabine and compared
them with 197 patients treated with CVI 5FU.45 The
pathological complete response was significantly
higher for capecitabine than CVI 5FU (25 per cent v.
13 per cent).
When is it safe to proceed
to surgery alone?
The selection of patients in whom initial surgical
resection is safe and who do not require preop-
erative radiotherapy remains a controversial issue.
The present authors believe that patients in groups
1 and 2, and even some categories of group 3, can
avoid preoperative radiotherapy in view of the sig-
nificant associated morbidity in terms of increased
pelvic and perineal post-surgical infections, and
significant late anorectal, urinary and sexual dys-
function.18 About 5–10 per cent of patients experi-
ence grade 3 or 4 late morbidity.47,48 Small bowel
tolerance is the main dose-limiting factor, and the
volume of the small bowel in the radiation field is
crucial,49 although only 1–2 per cent of patients
require early surgical intervention for small ­bowel
HEBK001-C06_p87-102.indd 92
damage. Mature results of the Swedish Rectal
Cancer Trial confirm problems such as late bowel
obstruction and abdominal pain.50 Additionally,
there are unexplained late cardiac effects and an
increased risk of a second malignancy.51 As follow-
up in the majority of studies is generally short,
there is likely to be a major underestimate of the
real risks of late effects.
Our caveat would be that in some cases of low
rectal cancer, it may be difficult to discriminate
between a cT2 and cT3 or even cT4 at the level of the
levators and below. High-quality MRI is not always
available. Low rectal tumours behave more aggres-
sively compared with cancers in the upper rectum.
High-quality surgery cannot always achieve a cura-
tive resection for locally advanced cancers that
extend below the levators. Currently, more aggres-
sive surgical approaches such as the ‘cylindrical’ or
extralevator approach are being explored, and these
may eventually be shown to be superior to standard
abdominoperineal excision. Preoperative chemora-
diation still has a major role in many patients with
low rectal cancer, however.
It should be stressed that the choice of not using
preoperative 5FU-based chemoradiotherapy repre-
sents a positive decision to forgo effective neoadju-
vant treatment. If the surgical histopathology sub-
sequently reveals a positive circumferential margin,
the optimal window for treatment may have been
lost.
SHORT-COURSE PREOPERATIVE
RADIATION VERSUS
CHEMORADIOTHERAPY
In Europe and Australia, two trials have directly
compared SCPRT with chemoradiation for patients
with resectable rectal tumours.52,53 The Polish study
found no difference in long-term outcomes of loco-
regional control, disease-free survival or overall sur-
vival (Table 6.1). Preliminary results from the Aus-
tralian study also failed to show differences in late
outcome. If the premise is accepted that in resectable
cancers, where the CRM is not threatened, SCPRT
and chemoradiotherapy are equivalent in terms of
outcomes such as local recurrence, disease-free sur-
vival and overall survival, then these results raise
questions about the importance of down-staging
and the effect of pathological ­complete response
08/02/13 5:58 PM
HEBK001-C06_p87-102.indd 93

Table 6.1. Trial design: preoperative radiotherapy versus preoperative chemoradiation in resectable rectal cancer.@

SHORT-COURSE PREOPERATIVE RADIATION VERSUS CHEMORADIOTHERAPY  93

Pathology
Disease- Pathological circumferential
Patients Patients Primary Local Overall free complete resection
Trial Duration (n) Randomization (n) TME end-point recurrence Metastases survival survival response margin
EORTC 54
1972–1984, 247 34.5 Gy v. 5FU 1 121 v. No Overall 15% v. 30% overall 59% v. 46% 72% v. 2.5% v. 5% Not Quirke
12 years 34.5 Gy 126 survival 15% at at 5 years 68% at
5 years 3 years
EORTC 1992–2004, 1011 45 Gy in 25 fractions 506 v. No Overall 17.1% v. 34.4% 64.8% v. 54.4% v. 5% v. 14% Not Quirke
2292127 12 years v. FUFA 1 45 Gy 505 survival 8.7% at overall 65.8% at 56.1% at
5 years 5 years 5 years
FFCD 1993–2005, 762 45 Gy in 25 fractions 367 v. No Overall 16.5% v. No data 67.9% v. No data 3.6% v. Not Quirke
920337 12 years v. FUFA 1 45 Gy 375 survival 8.1% at 67.4% at 11.4%
5 years 5 years
Polish 1999–2004, 316 25 Gy in 5 fractions/ 155 v. Yes Sphincter- 11% v. No data 67.2% v. 58.4% v. 1% v. 16% 13% v. 4%
trial52 5 years SCPRT v. FUFA 1 157 preserving 16.5% at 66.2% at 55.6% at (CRM)
50 Gy surgery 5 years 4 years 4 years
TROG 01- 2001–2006, 326 25 Gy in 5 fractions/ No data Yes Local 7.5% v. 72% v. 69% 74% v. 70% No data No data Not Quirke v. no
0453 5 years SCPRT v. 50.4 Gy 1 recurrence 4.1% at at 5 years data
PVI 5FU 3 years

EORTC, European Organisation for Research and Treatment of Cancer; FFCD, Fédération Francophone de Cancérologie Digestive; 5FU, 5-fluorouracil; FUFA,
5-fluorouracil plus folinic acid; PVI, protracted venous infusion; TME, total mesorectal excision; TROG, Trans-Tasman Radiation Oncology Group.
08/02/13 5:58 PM
 94  Preoperative radiotherapy and chemoradiotherapy for rectal cancer
on survival. Additionally, a positive CRM may not
be as significant an adverse prognostic factor after
SCPRT as after chemoradiotherapy.
Facilitating sphincter-
sparing procedures
Many surgeons consider the low position of some
rectal cancers (below 6 cm from the anal verge) to
inevitably require an abdominoperineal excision
resection, particularly if the sphincter is invaded.
In addition, a bulky anterior tumour in an obese
man with a narrow pelvis may prove technically
demanding to achieve sphincter-sparing surgery.
These situations have led to a commonly held
belief that preoperative radiation will allow an
increase in the rate of sphincter-preserving proce-
dures performed. Possibly, but not consistently, if
a bulky polypoidal tumour shrinks, this may allow
the surgeon to safely navigate around the mesorectal
fascia down on to the pelvic floor and achieve a low
anterior resection. This would not be possible with-
out prior radiation, in which case abdominoperine-
al excision may be required. More controversially is
the choice of the distal resection margin. Should this
be chosen as 1 cm below the distal edge of a tumour
that has shown major regression, or is it only onco-
logically safe to choose the distal margin on the basis
of the initial tumour location and size?
One study compared immediate and delayed sur-
gery after preoperative radiotherapy.55,56 Sphincter
preservation was achieved in 79 per cent of patients
with a long interval (4–6 weeks) following radio-
therapy, compared with 69 per cent of patients with
a shorter interval (2 weeks). A further randomized
study from this group suggests that dose escalation
of the radiotherapy with an endoluminal boost may
offer a higher rate of complete clinical response and
hence increase the chance of sphincter preservation
from 44 per cent to 76 per cent.57
Several non-randomized surgical series have
reported results of patients with clinically resect-
able rectal cancer, in whom clinical assessment by
their surgeon categorized the height of the can-
cer from the anal verge as requiring an abdomi-
noperineal excision. These patients then received
long-course preoperative radiotherapy and were
subsequently reassessed before definitive surgery.
Some studies used radiotherapy alone,55,58,59 and
HEBK001-C06_p87-102.indd 94
others used synchronous chemoradiation.36,60,61 The
putative hypothesis is supported by evidence from
randomized studies. Preoperative chemoradiation
appears to offer a 10 per cent13 or even a 20 per
cent12,62 higher chance overall in achieving sphinc-
ter-saving surgery. These trials were not specifically
designed to answer the question of the sphincter
preservation rate, however, and these data represent
subset analysis. The German data are particularly
liable to unforeseen biases, as the Zelen method of
randomization was used, and there are significant
differences in the numbers in each group.
RADIOTHERAPY ISSUES
Field Size
The optimal clinical target volume in preoperative
radiotherapy and chemoradiotherapy for resectable
rectal cancer before TME remains poorly defined.
Total mesorectal excision does not remove all nodal
stations potentially harbouring subclinical dis-
ease. Contouring a clinical target volume is a bal-
ance between encompassing structures at risk of
containing residual cancer cells after TME and the
desire to minimize normal tissue toxicity and surgi-
cal m
­ orbidity.
Many series in the pre-TME era mapped recur-
rence, including the seminal work from Gunderson
at the Mayo Clinic, amassed from ‘second-look’ sur-
gery.63 Previously, groups have made recommenda-
tions for clinical target volume contouring based on
observed sites of local recurrence.64–72 Historically,
wide-field radiotherapy using bony landmarks
was delivered to almost all patients. Early studies
defined the superior border as the junction of L5/
S1, but some studies treated up to the origin of the
inferior mesenteric artery at L4 and were associated
with significant morbidity.
Field sizes delivered in the USA are generally
larger than in Europe. The recommended field size
in one randomized phase II study suggested ‘The
superior border of the treatment volume was at
the L5–S1 junction with the inferior border a mini-
mum of 5 cm inferior to the distal-most extent of
the tumour or the anal verge as identified by a mark-
er on simulation’ [our italics].66 In the UK field sizes
are likely to be at least 4–5 cm shorter in the cranio-
caudal aspect.
08/02/13 5:58 PM

The studies of local recurrence after TME relate
to SCPRT, and there are very few relating to chemo-
radiotherapy. Lymph nodes and their precise loca-
tions are well described in Far Eastern series but not
generally in Western series. Few studies recommend
individualizing clinical target volume according to
site, stage and risk. Data on quality of life and late
morbidity are sparse. We recommend clinical tar-
get volume-customizing delineations based on site
and stage, with adaptations for high-risk features
according to clinical and MRI staging. Although
these proposed clinical target volume delineations
have not been evaluated in randomized trials, their
use appears rational and based on current evidence.
Total Dose
Conventionally, when 1.8 Gy per fraction is used,
total doses in the range 45–50.4 Gy have been deliv-
ered in the preoperative setting, and 50.4 Gy with the
option of a 5.4 Gy boost to the tumour bed in the
postoperative setting. It is assumed that the treat-
ment will be delivered 5 days per week, 1 ­fraction per
day, 1.8 Gy per fraction. The most appropriate dose is
not precisely known, but in association with chemo-
therapy the total radiation dose should be at least
45 Gy in fractions of 1.8–2 Gy. A boost of 4–6 Gy in
two to four fractions to the primary tumour is often
given, thus reducing the radiation dose to the entire
volume when chemoradiotherapy is given.
Ideal preoperative dose
Some SCPRT studies have used 20 Gy in five frac-
tions,73 but the Swedish Rectal Cancer Study, the
Dutch study and the CR07 study use 25 Gy in five
fractions, which most clinicians accept is a dose
fractionation that cannot safely be exceeded.
With the use of 1.8–2.0 Gy per fraction, how-
ever, the total dose may range from 45 Gy to 54 Gy
in most reported series. This upper limit is 20 per
cent higher than 45 Gy, and the balance between
improved local control and the increased risk of late
toxicity is continually debated.
The Colorectal Cancer Collaborative Group
meta-analysis confirmed that when preoperative
radiotherapy is used, a biologically equivalent dose
greater than 30 Gy is more effective in reducing local
relapse.16 A dose of 5 Gy daily for 5 days represents
a biologically equivalent dose of 37.5 Gy accord-
HEBK001-C06_p87-102.indd 95
RADIOTHERAPY ISSUES  95
ing to the linear quadratic equation, but in prac-
tice may be even higher. Early retrospective studies
suggest an increase in local control with a dose of
50 Gy compared with 40 Gy.74 More recent data from
phase II studies suggest that higher doses may be
associated with lower risks of local relapse.75–77
A sequential phase II study from Canada has been
reported. Three sequential schedules combined
radiation with infusional 5FU, escalated from 40 Gy
in 20 fractions to 46 Gy in 23 fractions and finally
to 50 Gy in 25 fractions. A statistically significant
difference in terms of local control was observed
for doses of 46 Gy and above, but there was no dif-
ference between doses of 46 Gy and 50 Gy.78 The
same study also appeared to show a trend to higher
pathological complete response rates with increas-
ing radiation dose of 13 per cent, 21 per cent and
31 per cent for 40 Gy, 46 Gy and 50 Gy, respectively.
Hyperfractionation
Short-course preoperative radiotherapy uses fewer
fractions at a higher dose per fraction (5 3 5 Gy),
which might be expected to cause more late mor-
bidity64,66 and which cannot allow integration of
chemotherapy. Hence, a number of studies have
used hyperfractionated radiotherapy with a view to
reducing late effects.79–81
Widder and colleagues reported SCPRT with twice-
daily fractions of 2.5 Gy to a total dose of 25 Gy within
1 week.79 The authors reported a high local control
rate (98 per cent after 4 years) along with low rates of
toxicity. It should be kept in mind, however, that theo-
retical anti-tumour efficiency is significantly reduced
in this fractionation protocol. A more recent study
modified SCPRT in rectal cancer to deliver twice-
daily fractions of 2.9 Gy to a total dose of 29 Gy in 1
week immediately before surgery.82 Adjuvant chemo-
therapy was intended to be offered subsequently to
patients with any pathological tumour assessment of
stage II or higher in the resected specimen.
Brachytherapy
High-dose-rate intraluminal brachytherapy (HDR-
ILBT) has the advantage of high conformality, i.e.
a rapid fall-off of radiation dose, which allows the
delivery of a high dose to the tumour while spar-
ing normal surrounding structures such as the
08/02/13 5:58 PM
 96  Preoperative radiotherapy and chemoradiotherapy for rectal cancer
contralateral normal rectal mucosa, bladder and
small bowel.83,84 Limited data are available evalu-
ating the advantages of HDR-ILBT with external
beam radiotherapy (EBRT) compared with EBRT
alone.85 High-dose-rate intraluminal brachytherapy
for advanced or inoperable tumours of the rectum
has been used both in the palliative setting and to
dose escalate after chemoradiation for curative treat-
ment.86,87 It has also been used as a single modality in
the preoperative setting, with 30 per cent pathologi-
cal complete response;83 again, however, there are
limited data regarding HDR-ILBT as a boost to the
gross tumour volume in combination with preop-
erative chemoradiation for rectal cancers.
In principle HDR-ILBT as a component or fol-
lowing chemoradiation may avoid a colostomy by
increasing down-staging and facilitating sphincter
preservation57 or by potentiating a non-operative
approach.84
Intensity-Modulated Radiotherapy
Technical advances such as IMRT allow greater
precision and sparing of normal surrounding
structures such as small bowel compared with con-
ventional two-dimensional or three-dimensional
planning. Intensity-modulated radiotherapy may
allow improved compliance or facilitate dose escala-
tion without increasing late morbidity. In addition,
there was no difference with regard to late toxicity
for any of the four arms in the European Organisa-
tion for Research and Treatment of Cancer (EORTC)
22921 study trial: 522 patients retained their sphinc-
ters, and of these only 1.4 per cent required surgery
for small bowel complications. This low level of late
morbidity calls into question the need to deliver
IMRT with the aim of reducing small bowel toxicity.
Other cytotoxic drugs
The addition of oxaliplatin and irinotecan to 5FU-
based chemotherapy or oral fluoropyrimidines has
been explored within a chemoradiotherapy sched-
ule in numerous phase II studies in an attempt
to increase tumour shrinkage before surgery and
­potentially mirror the success of oxaliplatin in deal-
ing with distant micro-metastases in the adjuvant
setting in colon cancer.20,21
HEBK001-C06_p87-102.indd 96
Phase II trials provide additional toxicity data
and potential regimens for future phase III rand-
omized trials in patients with rectal cancer. The
Radiation Therapy Oncology Group (RTOG) 0247
trial, a randomized phase II trial, compared capecit-
abine administered 5 days per week and weekly
oxaliplatin plus radiation administered before sur-
gery followed by nine cycles of postoperative oxali-
platin with 5FU and folinic acid chemotherapy
(FOLFOX) with irinotecan on a weekly schedule
substituted for oxaliplatin.
Another phase II trial, E3204, combines capecit-
abine administered 5 days per week plus weekly
oxaliplatin and bevacizumab with radiation every
other week; postoperative patients receive 12 cycles
of FOLFOX and bevacizumab.
Two randomized phase III studies have examined
one versus two cytotoxic drugs (Table 6.2).22,23 In
the Italian Studio Terapia Adjuvante Retto (STAR)
trial, oxaliplatin added little to early assessable
end-points but increased toxicity when added to a
standard preoperative chemoradiation regimen for
locally advanced rectal cancer. There were no signif-
icant differences in pathological complete response,
local tumour response or tumour down-staging
between patients who received FU-based chemora-
diation with weekly oxaliplatin infusions.22
The Fédération Francophone de Cancérologie
Digestive (FFCD) Fédération Nationale des Centres
de Lutte Contre le Cancer (FNCLCC) ACCORD
12 trial (NCT00227747) compares neoadjuvant
preoperative capecitabine combined with 45 Gy in
25 fractions over 5 weeks against capecitabine and
oxaliplatin partnered with 50 Gy in 25 fractions over
5 weeks. Only data on toxicity and early pathological
and surgical end-points are currently available.23,37
The design of this study is poor, because capecitab-
ine in combination with 45 Gy (arm A) is compared
with capecitabine/oxaliplatin and 50 Gy (arm B).
The pathological complete response appears higher
(18.8 per cent) in the capecitabine/oxaliplatin arm
(arm B) than in arm A (13.8 per cent), but it is not
clear whether this reflects the addition of oxalipla-
tin or the higher radiotherapy dose.23 It remains to
be seen whether disease-free survival and overall
survival are improved by the strategy of adding
oxaliplatin in this setting, but in the meantime the
addition of irinotecan and ­oxaliplatin to 5FU-based
chemoradiation in patients with resectable tumours
remains investigational.
08/02/13 5:58 PM
 THE FUTURE  97

Table 6.2. Ongoing phase III trials of neoadjuvant chemoradiation in resectable rectal cancer.
Concurrent
chemoradiotherapy Radiotherapy
Study (CRT) randomization dose Patients (n) Preoperative treatment Comments
NSABP R-04, Capecitabine or 5FU/ 50.4 Gy in 28 1606; Recommended to consider Primary end-
NCT00058474 CRT v. capecitabine fractions and closed to ECOG 5204 point: 3-year
or 5FU 1 oxaliplatin 55.8 Gy for recruitment locoregional
(every 2 weeks)/CRT fixed tumours disease control
CAO/ARO/AIO CI 5FU (days 1–15, 50 Gy in 25 1259; 5FU 34 or FOLFOX 34 Primary end-
04 22–35)/CRT v. CI fractions over closed to point: disease-
5FU 1 oxaliplatin as 33 days recruitment free survival at
radiosensitizer (days 3 years
1, 8, 22, 29)
PETACC 6/ Capecitabine/ 45 Gy in 25 Open Capecitabine 36 or XELOX Primary end-
EORTC 40054, radiotherapy v. fractions over 36; adjuvant chemotherapy point: disease-
NCT00766155 capecitabine 1 33 days 6 regimen continues free survival
oxaliplatin (every 5.4 Gy boost preoperative agents
week)/radiotherapy

CI, continuous infusion; ECOG, Eastern Cooperative Oncology Group; FOLFOX, oxaliplatin with 5-fluorouracil
and folinic acid chemotherapy; 5FU, 5-fluorouracil; XELOX, capecitabine with oxaliplatin.

Integration of biologicals Tumors (RECIST) criteria was 19 per cent versus 13

Integration of targeted drugs such as cetuximab
into preoperative chemoradiation schedules in rec-
tal adenocarcinoma is attractive in principle. The
preliminary results of chemoradiation clinical trials
with cetuximab, on the early clinical end-point of
pathological complete response, are disappointing
however. Cetuximab can lead to G1 or G2/M-cell
cycle arrest; if only a small proportion of cells with-
in the tumour are affected, this decrease in prolif-
eration could impact on the chance of achieving a
complete pathological response.
A large multinational randomized phase II study
EXPERT-C (NCT00383695) has compared neoad-
juvant therapy comprising oxaliplatin, capecitabine
and chemoradiotherapy with or without cetuxi-
mab in 164 patients. The study was completed in
July 2008, and results may throw more light on
combinations of cetuximab and chemoradiation
in the clinical setting in locally advanced rectal
cancer. The combination may yet reproduce the
improvement in long-term results achieved when
cetuximab has been combined with radiation alone
in studies of head and neck cancer.88 Also, in a
randomized phase II trial of squamous cell carci-
noma of the oesophagus, the overall response rate
according to Response Evaluation Criteria In Solid
per cent for the addition of cetuximab to cisplatin
and 5FU.89 Median progression-free survival was
9.5 months for cetuximab with cisplatin and 5FU
and 5.5 months for cisplatin and 5FU, demonstrat-
ing that the response may not be the best end-point.
The integration of bevacizumab has consider-
able preclinical rationale. Experimental studies in
human tumour xenograft models have shown that
vascular endothelial growth factor (VEGF) block-
ade serves as a potent and non-toxic enhancer of
radiation. Anti-VEGF decreases interstitial pres-
sure, increases oxygenation, and reverses radiation
resistance conferred by hypoxia. Few phase II tri-
als have been reported, but the combination with
chemoradiotherapy appears potentially deliverable
with acceptable toxicity. There are five other ongo-
ing or recently closed phase III trials registered on
the http://clinicaltrials.gov website.
THE FUTURE
The best opportunity to improve survival in patients
with rectal cancer will require continued focus on
adjuvant chemotherapy strategies, since the devel-
opment of metastases is the predominant cause of
recurrence and death. At the same time, we need to

HEBK001-C06_p87-102.indd 97 08/02/13 5:58 PM

 98  Preoperative radiotherapy and chemoradiotherapy for rectal cancer
achieve better documentation and understanding of
pursuing detailed assessment of acute and chronic
toxicity and the risk of second malignancies.
Additionally, if treatment strategies are to be suc-
cessful in patients with rectal cancer, then a degree of
individualization in the cytotoxic chemotherapy and
biological agents – and even further individualization
of radiation – is required. To optimize treatment, we
need a deeper understanding of tumour biology.
CONCLUSION
A pelvic MRI scan is an essential part of the initial
staging of all patients with rectal cancer 0–15 cm
from the anal verge and can help to define the most
appropriate preoperative strategy. There is a well-
established role for both SCPRT and down-staging
long-course chemoradiation. For chemoradiation,
however, there is no consensus regarding the opti-
mum dose, fractionation, field size or chemotherapy
schedule. Current evidence does not support the
degree of response to chemoradiation (e.g. patho-
logical complete response; down-sizing the prima-
ry tumour; sterilizing the regional nodes; tumour
regression grades; residual cell density) as a valid
surrogate for long-term local control or survival.
Current trials suggest that in resectable cancers
where the CRM is not threatened, SCPRT and chem-
oradiotherapy are equivalent in terms of outcomes
such as local recurrence, disease-free survival and
overall survival. In view of the high risk of metastatic
disease, research strategies should be explored to
address the problem in the preoperative setting.
More rationally designed preclinical and transla-
tional studies (with recognized negative predictive
factors such as k-ras mutations, b-raf mutations and
epidermal growth factor receptor (EGFR) gene copy
numbers) may therefore help select out inappropri-
ate patients and determine the optimal sequence of
chemotherapy and biological triple combinations.
Only then can we move on to perform large rand-
omized phase III trials.
Recommendations
l A pelvic MRI scan is an essential part of the
initial staging of all patients with rectal cancer
0–15 cm from the anal verge.
HEBK001-C06_p87-102.indd 98
l Current evidence does not support the degree
of response to chemoradiation (e.g. pathologi-
cal complete response; down-sizing the primary
tumour; sterilizing the regional nodes; tumour
regression grades; residual cell density) as a
valid surrogate for long-term local control or
survival, although down-staging may predict a
role for adjuvant chemotherapy.
l There is no evidence that conventional preop-
erative chemoradiation can facilitate sphincter-
sparing surgery. It should not be a primary
reason for administering preoperative chemora-
diation, although in the case of excellent down-
staging this may prove a bonus.
l There is no evidence for increased efficacy of
chemoradiotherapy over SCPRT in moderate-
risk resectable cancers.
l Preoperative chemoradiation using 45–54 Gy
over 5–6 weeks with an interval to allow
response and shrinkage is recommended where
the MRI confirms a ‘threatened’ or breached
circumferential margin, or where there is a
radiologically unresectable cancer with disease
outside the mesorectum, i.e. surgery is not pos-
sible without leaving tumour within the pelvis.
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Total mesorectal excision for
rectal cancer
Brendan Moran
Introduction
There have been several key advances in the opti-
mal management of rectal cancer, but none so
important as standardization and improvement
in the appropriate surgical procedure. In addition
to surgical advances, neoadjuvant and adjuvant
radiotherapy and chemoradiotherapy, preoperative
imaging (by computed tomography (CT) of the
chest and abdomen looking for metastatic disease,
and by magnetic resonance imaging (MRI) to assess
local tumour extent), pathological assessment and
audit have all contributed to better results for
this complex but eminently curable cancer. These
advances, and complex management decisions, are
undoubtedly best coordinated by a multidiscipli-
nary team approach, but surgery, and the surgeon,
are the key to optimal decision-making and out-
come. Multidisciplinary team management should
be individualized to each patient with rectal cancer
and should focus on helping the surgeon and the
patient choose the best course of action. The pre-
operative MRI provides optimal local staging and
is a key visual component in the multidisciplinary
team discussion of the optimal management of a
patient with rectal cancer. The combination of clin-
ical examination and good-quality MRI facilitates
selection for neoadjuvant (preoperative) radiother-
apy or chemoradiotherapy. This decision is crucial
HEBK001-C07_p103-123.indd 103
7
and requires a balance between the desired effect
on the tumour and the immediate and long-term
side effects associated with radiotherapy for rectal
cancer.
The benefits of neoadjuvant therapy for locally
advanced tumours are now generally accepted, with
good evidence for both down-staging and down-
sizing after optimal neoadjuvant therapy. Debate
persists as to what the term ‘locally advanced’
means, and until recently the definition lacked
the objective fine detail of good-quality MRI. The
evidence for neoadjuvant therapy is strongest for
a reduction in local recurrence in operable rec-
tal cancer and has been reported in a number of
randomized controlled trials such as the Swedish,
Stockholm, Dutch and UK CR07 trials. There is lit-
tle evidence of a survival benefit from radiation in
these trials, however, with well-documented reports
of immediate and long-term side effects associated
with radiotherapy. Unquestionably, tissue heal-
ing is impaired by radiotherapy, with an increase
in perineal wound failure in patients who have an
abdominoperineal excision and an increase in anas-
tomotic leakage when reconstruction by anterior
resection is performed. Additionally, in the medi-
um to long term, bladder, bowel and sexual func-
tion are impaired by radiotherapy. There are also
increasing reports of long-term complications such
as an increase in second primary tumours, excess
11/02/13 3:51 PM
 104  Total mesorectal excision for rectal cancer
cardiovascular deaths, and reoperation for bowel
obstruction, all of which emphasize the need for a
selective approach. There is no doubt that patients
with advanced tumours benefit from radiotherapy
and, if used in rectal cancer, radiotherapy should be
given before surgery with randomized trials sup-
porting this strategy.
There is now general agreement that the opti-
mal surgical treatment involves the concept of
total mesorectal excision (TME), and that an R0
excision (all margins of the excised specimen free
of tumour at detailed pathological assessment)
is crucial. For this reason, the relationship of the
tumour to the mesorectal fascia is key in that a
tumour invading or breaching the mesorectal
fascia will have an involved margin at TME sur-
gery and will not be cured by TME alone. A key
advance of staging MRI is the ability to visualize
the mesorectal fascia and to accurately determine
whether the mesorectal fascia is clear of tumour,
definitely involved or possibly involved (the lat-
ter often categorized as ‘threatened’) by tumour.
This crucial information on the relationship of
the tumour to the mesorectal fascia allows an
informed decision on whether TME alone is
likely to be curative (clear margins), indicates
patients who definitely need neoadjuvant thera-
py (involved margin), and facilitates discussion
on the risks and benefits in patients with a threat-
ened margin. These categories are more difficult
to define in the low rectum (at or below the level
of the levators), where the mesorectum tapers
out and the margins are more likely to be threat-
ened. For this reason, we have an ongoing inter-
est, research programme and educational initia-
tive in the staging and management of low rectal
cancers (see www.lorec.nhs.uk).
The broad principles of TME surgery remain
the same, whether the technique is open surgery,
laparoscopic TME or robotic TME. The principles
of optimal visualization and more precise dis-
section, improved haemostasis and less collateral
damage by diathermy are key. Modern advances
in technology have helped in these areas. Knowl-
edge of the anatomical structures, and their rela-
tionships in the pelvis, are essential for surgeons,
regardless of the surgical technique used. It is
noteworthy that surgical observations and atten-
tion to the fine detail of the anatomical structures
at surgery have been a defining force in developing,
HEBK001-C07_p103-123.indd 104
refining and advancing the complex anatomy of
the human pelvis (see Chapter 2).
Fundamental principles of
total mesorectal excision
surgery
The fundamental components of TME surgery
incorporate a number of principles and include the
following:
l Peri-mesorectal ‘holy plane’ sharp dissection
by diathermy and scissors under direct ­v ision:
three-directional traction and counter-­
traction is a vital principle for diathermy dis-
section, as it is essential that the areolar tissue
is ‘on stretch’ if holy plane dissection is to be
accurate.
l Specimen-oriented surgery and histopathol-
ogy, with the objective of an intact mesorec-
tum with no tearing of the surface and no
circumferential resection margin (CRM)
or distal margin involvement (naked eye
or microscopic).
l Personal naked-eye assessment as audit for
obvious CRM involvement as the principal
immediate outcome measure: this should be
combined with objective assessment of the
whole specimen by the pathologist, as this
confirms the optimal planning and completion
of the surgery. Surgeons and oncologists may
also base postoperative therapy on this pathol-
ogy report, although there must always be a
sense of the ‘horse having bolted’ if cancer has
perforated through the resected specimen and
radiotherapy or chemoradiotherapy (CRT) was
not given before surgery. An involved margin
generally represents a failure of management
planning or surgical technique, or both.
l Recognition during surgery and preservation
of the autonomic plexuses and nerves on which
sexual and bladder function depend.
l A major increase in anal preservation and reduc-
tion in the number of permanent colostomies by
skilful extension into the depths of the pelvis.
l Stapled low pelvic reconstruction, usually using
the Moran triple stapling technique (described
later), plus creation of a short colon pouch or a
side-to-end anastomosis to the low rectum or
anal canal.
11/02/13 3:51 PM
 BASIC PRINCIPLES OF SURGERY FOR RECTAL CANCER  105

BASIC PRINCIPLES OF SURGERY

FOR RECTAL CANCER

Rectal cancer, as defined by an adenocarcino-

ma with its lower edge at or within 15 cm of the
anal verge, is a common cancer and accounts for
approximately 30 per cent of all colorectal cancers.
Surgical excision by anterior resection is curative in
most cases. The term ‘anterior resection’ defines an
operation whereby the inferior mesenteric artery
has been ligated and reconstruction is by anasto-
mosis of the proximal colon to the distal remnant.
Anterior resection is neither required nor appropri-
ate for all patients with rectal cancer. Early tumours
(perhaps in the region of 5–10 per cent of all
patients with rectal cancer, although this percentage
may increase with screening) can be treated by local
excision alone in selected patients (see Chapter 11), Figure 7.1. Inferior mesenteric angiogram outlining
and tumours involving the anal sphincter complex the blood supply to the rectum and demonstrating the
or levator muscle (approximately 10–15 per cent) absence of any significant arterial input from the lateral
require excision of the sphincter complex with a pelvic side-wall.
permanent stoma (see Chapter 8). Thus, restora-
tive anterior resection is required and feasible in
the description and popularization of TME with
approximately 70–80 per cent of all patients with
specimen-oriented surgery. Finally, circumferential
rectal cancer. For each patient, however, the feasi-
pathology reports on the adequacy of excision mar-
bility and benefits of restorative resection will ulti-
gins on the resected specimen and allows continu-
mately depend on the tumour, the patient and, to a
ous quality control of the staging, MDT decisions
lesser extent, the surgeon. Tumour-dependent fac-
and surgical precision.
tors are predominantly the distance of the tumour
The principles of optimal surgery for rectal can-
from the anal verge, the fixity of the tumour, and the
cer revolve around the embryology and anatomy of
presence or absence of diffuse metastatic disease.
the rectum, whereby the lymphatic drainage (which
Patient-dependent factors include the body habitus,
is associated with the arterial blood supply; Figure
the size and depth of the pelvis, and anal sphincter
7.1) is almost exclusively proximal and is generally
integrity and function. Surgeon-dependent factors
confined within the mesorectal fascia.
include the availability of resources (e.g. stapling
The principles of TME focus on specimen-ori-
instruments, adequate retractors) and the availabil-
ented surgery, whereby completeness and intact-
ity of a suitably experienced surgical assistant and
ness of the specimen are crucial factors, such that
theatre team. The principles of anterior resection
ideally it should be one recognizable block of tis-
for rectal cancer currently revolve around what has
sue whose orientation and former relations can
been described as ‘circumferential awareness’ incor-
be identified. In most cases, naked-eye inspection
porating circumferential staging, circumferential
provides the initial necessary quality control. Visual
down-staging, circumferential surgery and circum-
inspection of the front of a well-performed TME
ferential pathology. Circumferential staging incor-
specimen should show three clear landmarks:
porates clinical examination and, more latterly, the
addition of cross-sectional imaging, in particular l the cut edge of the peritoneal reflection;
abdominal and pelvic CT and pelvic MRI. Circum- l the smooth shiny anterior surface of the ante-
ferential down-staging or down-sizing is achieved rior mesorectum of the middle third
by preoperative radiotherapy or chemoradiothera- (the rectogenital septum);
py (neoadjuvant therapy; see Chapter 6). The con- l the almost bare anterior aspect of the anorectal

cept of circumferential surgery has emanated from muscle tube in the lowest anterior resections.

HEBK001-C07_p103-123.indd 105 11/02/13 3:51 PM

 106  Total mesorectal excision for rectal cancer
Figure 7.2. Total mesorectal excision specimen illustrating
the shiny mesorectal fascia surrounding the fatty
mesorectum. A linear stapling gun occludes the lumen,
as used in the Moran triple stapling technique.
Laterally, the fatty mesorectum expands distally
beyond an anteroposterior groove made by the
nervi erigentes so that an embryologically per-
fect specimen has a lateral dilatation distally, cor-
responding with the part related to the inside of
the levator muscles beyond their origins from the
pelvic side-wall (Figure 7.2). Posteriorly, a perfect
specimen exhibits perfectly curved ‘buttocks’ with
a central midline groove corresponding to the ano-
coccygeal raphe.
Distal mesorectal spread of the tumour rarely
extends more than 2–3 cm beyond the lower pal-
pable luminal edge of the tumour, although for
safety reasons a distal mesorectal clearance of 5 cm,
where feasible and available, is recommended. This
was the fundamental principle underpinning the
concept of TME, which has now become accepted
as the optimal surgical procedure for patients with
resectable mid- and low rectal cancer. There has
been some confusion that we have advocated TME
for all rectal cancers; but TME is not necessary for
tumours of the upper rectum provided the mes-
orectum and muscle tube can be divided 5 cm distal
to the lower edge of the tumour and a mesorectal
transection, rather than TME, can be performed,
possibly diminishing the postoperative surgical
complications such as a reduction in the anasto-
motic leak rate.
Other major advances facilitating safe restora-
tion of continuity, even in low tumours, were the
development and widespread availability of sta-
HEBK001-C07_p103-123.indd 106
pling instruments,1 the recognition that adenocar-
cinoma rarely spreads distally in the muscle tube,
and the recognition that a 2 cm clearance beyond
the macroscopic tumour provides a safe distal mar-
gin and even less than 1 cm may be adequate for
ultra-low tumours.2
It is important to recognize that, even at its most
scientific, surgery is primarily a craft with very spe-
cial challenges and rewards for excellence. Surgery is
not amenable to study by the same methods as those
applicable to drugs or radiotherapy treatments, and
yet surgical technique has by far the greatest impact
on rectal cancer outcomes. The randomized con-
trolled clinical trial has so far contributed remark-
ably little to the development of surgical technique
in colorectal surgery or most other surgical special-
ties. Even though variations in technique, such as
open, laparoscopic or robotic surgery, lend them-
selves to comparative studies and indeed to rand-
omization, in all such trials the cohort studied can
be only a selected subset of the patient population,
with the most difficult patients excluded and oper-
ated on by open surgical techniques. For this rea-
son, the results of such trials are not applicable to
all patients and merely represent comparative out-
comes, generally in the more favourable cases.
The technique of TME has never been critically
evaluated by a randomized trial, and nor is likely
to be. In this difficult and complex surgery for rec-
tal cancer, the devil is in the detail, and attention
to detail using TME concepts results in optimal
­outcome.
Preoperative Assessment, Planning
and Preparation
Preoperative preparation is essential, and to fail
to plan is to plan to fail. The assessment of a rec-
tal cancer, local staging and management of a rec-
tal cancer are summarized in Figures 7.3 and 7.4,
which, although specific for low rectal cancer, apply
to any rectal adenocarcinoma.
Critical decisions in lower-third cancers
One focal area of current interest centres on the
anatomical and embryological fact that the mes-
orectal envelope tapers down in this (infralevator)
lower third to appear very thin indeed, particu-
larly on the crucial coronal oblique MRI cuts on
11/02/13 3:51 PM
 BASIC PRINCIPLES OF SURGERY FOR RECTAL CANCER  107

Suspicion of Rectal Cancer

History, patients perspective and Rectal Examination (PR) by

Experienced Surgeon + CNS ideally present

Too painful PR Rigid Sigmoidoscopy

Mobility
Distance in cms Distance in cms from
from anal verge dentate line
EUA to lower edge to lower edge
(Examination
Under Anaesthetic)
Colonoscopy

Biopsy

Surgeon and CNS

Squamous Other:
Adenocarcinoma Adenoma
Carcinoma Prostate/Carcinoid

Treatment Staging Repeat biopsy Treatment

Systemic Staging CT - Chest

and Abdomen

Disseminated Resectable
No metastases
disease metastases

Local Extent primary

(Figure 7.5)

Pallative treatment ± Chemotherapy ± Radiotherapy ± Local Ablation

CNS, clinical nurse specialist; CT, computed tomography.

Figure 7.3. Suggested algorithm for assessment of rectal cancer.

HEBK001-C07_p103-123.indd 107 11/02/13 3:51 PM

 108  Total mesorectal excision for rectal cancer

Low Rectal Cancer

MRI - Low rectal protocol

PR by experienced surgeon EOUS (Endo-anal ultrasound)

MDT

‘Good’ ‘Ugly’
‘Bad’
(early tumour uT1, (Advanced uT3/T4, mr
(mrT3N1-2, EMVI)
mrT1) T3/T4)

SCRT/CRT? CRT

Restage

PR, MRI, EAUS Systemic (CT)

Tumour Clinical and radiological complete

present response
Consider
Deferral of surgery
‘watch and wait’
Recurrence
Surgery Intensive Follow-up

Intensive Follow-up 5–10 years

Local excision Anterior Resection (AR) Abdomino Perineal
perianal, TEM (Including Intersphincteric) Excision (APE)

Defunctioning Stoma Intersphinteric Extralevator ELAPE

Perineal closure
Primary Suture

Primary Suture Biological mesh Omentum Muscle flap

Back to MDT for post op discussion

CRT, chemoradiotherapy; CT, computed tomography; EAUS, endoanal ultrasound; MDT, multidisciplinary team;
MRI, magnetic resonance imaging; PR, per rectal examination; SCRT, short-course radiotherapy; TEM, transanal
endoscopic microsurgery.

Figure 7.4. Suggested algorithm for local assessment of low rectal cancer.

which decisions in modern multidisciplinary teams
are made. On such an MRI it is tempting to pre-
dict that this tapering and narrowing area of the
mesorectum will constitute a hazardous margin;
thus, a decision may be made to administer preop-
erative down-staging neoadjuvant therapy or even
choose abdominoperineal excision for fear of mar-
gin involvement when in fact a carefully oriented
axial oblique sequence with the axial cuts precisely
at right-angles to the tumour segment may dem-
onstrate a potentially safe clearance. In such cases,
where the cancer is below the levator origins on
MRI, it is essential that an experienced surgeon
examines the patient to establish free mobility of
the tumour in the conscious patient (with muscle
tone). In the author’s opinion, this clinical observa-
tion of mobility on the sphincter complex and adja-
cent organs almost invariably means that a TME will
be an achievable surgical objective (see Figure 7.5).
It does not get away from the other issues of the
higher incidence of internal iliac and particularly
obturator node involvement in tumours less than
6 cm from the anal margin.3
A rectal neoplasm should be assessed by an expe-
rienced clinician performing a rectal examination
and rigid sigmoidoscopy. The height of the lower
edge of the tumour should be measured by rigid
sigmoidoscopy with the patient awake and recum-

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 BASIC PRINCIPLES OF SURGERY FOR RECTAL CANCER  109
Figure 7.5. Total mesorectal excision. Dissection follows
the dotted line. Transection of the muscle tube should be
3–5 cm below the luminal distal edge of the tumour as
distal mesorectal spread has been documented so that
mesorectal transection may be adequate for upper rectal
tumours.
bent in the left lateral position. The surgeon should
assess the integrity of the anal canal and if possi-
ble assess the mobility, or otherwise, of a palpable
tumour. The neoplasm should be biopsied to con-
firm the diagnosis. Biopsy may be deferred to a sub-
sequent urgent colonoscopy, however.
One useful procedure is to re-examine the lesion,
particularly a low rectal cancer under sedation at
colonoscopy. Occasionally an examination and
biopsy under general anaesthetic is required, and
even today this may be a useful addition in the
work-up of a patient with a rectal cancer.
The remainder of the colon should be assessed to
look for synchronous neoplasia (present in 3–4 per
cent of patients) by colonoscopy, CT colonography
or barium enema. Colonoscopy has the advantage of
allowing biopsy or removal of synchronous lesions
such as polyps. The benefits of CT colonography
are the ability to stage the abdominal cavity and to
outline the proximal bowel in patients with stenotic
lesions where colonoscopy may not be ­feasible.
Current best practice also incorporates staging
for systemic disease by chest and abdominal CT scan
and local pelvic staging of the rectal tumour, ide-
ally by MRI to assess the relationship of the tumour
to the mesorectal fascia (see Chapter 4 and 5).
Additionally, MRI can provide details of relevant
HEBK001-C07_p103-123.indd 109
pelvic anatomy, such as ovarian or uterine pathol-
ogy in female patients and prostatic enlargement
in male patients, all of which may limit access. In
some patients, synchronous treatment of ovarian
and rectal pathology may be performed.
The clinical details and radiological investiga-
tions of all patients with rectal cancer should ideally
be discussed at a colorectal multidisciplinary team
meeting to optimize the management strategy,
which in some cases includes neoadjuvant therapy.
Patient consent and immediate
preoperative care
Medical conditions such as diabetes, hyperten-
sion, and cardiac and pulmonary diseases should
be ­optimized. Arrangements should be in place for
postoperative critical care if required. The patient
should be consented and sites marked in case a stoma
is required. It is prudent to consent for a permanent
stoma, in addition to a temporary defunctioning,
should an unexpected event render this necessary.
In addition to the complications after any intestinal
resection, such as leakage and haemorrhage, the pos-
sibility of sexual and bladder dysfunction needs to
be documented in the consent form for rectal can-
cer surgery. These latter complications usually result
from injury to the pelvic autonomic nerves.
In female patients, the possible need for
oophorectomy should be discussed. Consent for
oophorectomy should be documented in case
the tumour involves the ovaries or the patient
has a family history of ovarian cancer or requests
oophorectomy. A personal preference is also to seek
consent for appendicectomy to treat synchronous
or prevent metachronous appendiceal pathology.
Unlike current practice in surgery for colon can-
cer, an empty large intestine is desirable for restora-
tive rectal cancer surgery, particularly if there is a
need for temporary defunctioning. An ileostomy
proximal to a full colon may not reduce the con-
sequences of an anastomotic leak. Optimal bowel
preparation can be achieved by combining clear
fluids by mouth for 48 h before surgery with oral
laxatives. There is emerging evidence that the
non-prepared colon increases complications after
­restorative rectal cancer surgery, and many sur-
geons who abandoned bowel preparation on the
back of experiences with colonic resection are
reverting back to full mechanical bowel preparation
for restorative rectal cancer surgery.
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 110  Total mesorectal excision for rectal cancer

Systemic antibacterial agents, including anaero-

bic cover such as with metronidazole, are given at
induction of anaesthesia and continued for 24 h
post-surgery.
Deep venous thrombosis (DVT) prophylaxis is
commenced by a combination of heparin or its
analogues (depending on the use of epidural anaes-
thesia). The risk of DVT must always be balanced
against the risk of bleeding, which is catastrophic
if into the dural space and potentially catastrophic
during pelvic dissection. For these reasons, antico-
agulation is best withheld in the immediate preop-
erative period. The use of mechanical calf com-
pression devices, once the patient is positioned
on the operating table, and in the postoperative
period, has been shown to be effective and gener-
ally safe.

Figure 7.6. Midline incision extending from the

Patient Positioning
The lithotomy–Trendelenburg position is opti-
mal as it allows peranal palpation, inspection and
washout, together with insertion of the circular
staple gun to complete the anastomosis. Addition-
ally, a second assistant can stand between the legs.
The patient is kept horizontal during the abdomi-
nal phase of the operation and can then be tilted
head down by 15–208 or more to facilitate the pel-
vic dissection. It is important not to maintain steep
Trendelenburg positioning for extended periods, to
reduce the risks of calf compartment syndrome.
Good lighting is essential. Optimal lighting can
be obtained by readjusting the movable focused
operating lights during different phases, using a
headlight (which many surgeons find irksome for
a prolonged procedure), and using retractors with
integrated lights.
On-Table Examination, Skin Incision
and Abdominal Exploration
A rectal examination before painting and draping is
mandatory and must be supplemented by a vaginal
examination in female patients.
A long vertical midline incision provides optimal
access to the abdomen and pelvis and may need to be
extended from the pubic symphysis to the xiphister-
num in patients who are overweight (Figure 7.6).
symphysis pubis, which may need to be extended to the
xiphisternum. The optimal site for a defunctioning stoma is
on the right side (defunctioning lower right ileostomy) and is
marked preoperatively by an enterostomal therapist. A site
is also marked in the left iliac fossa in case a permanent
stoma is deemed necessary.
Although some advocate a long transverse inci-
sion or even a modified extended Pfannensteil inci-
sion, access to the splenic flexure and pelvis is infe-
rior compared with a midline incision.
The abdominal cavity is fully palpated, with par-
ticular attention directed to the liver and spleen,
greater omentum, stomach and small bowel, and
the entire colorectum, including the appendix. The
surgical procedure is then planned, including the
sequence. For example, if a low anterior resec-
tion is planned mobilization of the splenic flexure
is almost always needed. Personal preference is to
complete this manoeuvre at the beginning while
still fresh and to avoid the temptation to omit this at
the end of a long procedure and thus compromise
on tension and blood supply to the neorectum.
Commencing the Dissection and
Splenic Flexure Mobilization
The operating surgeon stands on the left side of the
patient. The assistant on the right lifts the sigmoid

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 BASIC PRINCIPLES OF SURGERY FOR RECTAL CANCER  111
colon anteriorly and to the patient’s right. The peri-
toneal reflection on the left side of the colon (the
white line of Toldt) is identified and divided by scis-
sors, or more commonly diathermy, and followed
cranially towards the splenic flexure. The plane in
the left upper quadrant between the colon and the
urogenital structures (Gerotas fascia surrounding
the kidney and the gonadal vessels) is developed.
At this juncture, if the spleen is mobile on the dia-
phragm, a large moist swab placed gently between
the spleen and diaphragm helps to push the spleen
into view and facilitates splenic flexure mobiliza-
tion (Figure 7.7). The greater omentum is now
retracted anteriorly and to the patient’s left, and the
bloodless plane between the transverse colon and
omentum is developed by sharp scissors dissec-
tion or diathermy incision. The apex of the splenic
flexure attachments are visualized by downwards
colonic traction from the right side of the patient
with counter-traction by a retractor under the left
ribcage. The assistant on the patient’s right, in addi-
tion to colonic traction, insinuates a finger behind
the colon on the left. Division of the apical lateral
colonic attachments is performed by an operator
who stands either on the patient’s left or temporar-
ily between the patient’s legs.
Figure 7.7. Mobilization of the splenic flexure, incising
lateral attachments.
HEBK001-C07_p103-123.indd 111
Ligation and division of the inferior
mesenteric vessels
The left-sided colonic mobilization is continued
inferiorly by the left-sided operator identifying the
ureter (usually positioned medial to the gonadal
vessels and crossing the bifurcation of the common
iliac artery) and the fascial covering of the upper-
most part of the mesorectal package. This manoeu-
vre is facilitated by the right-sided assistant apply-
ing traction on the sigmoid, anteriorly and to the
right, taking care not to damage the mesentery of
the colon. Once the plane has been developed at the
pelvic brim to just beyond the midline, a small swab
is pushed behind the colon and rectal mesentery at
the level of the pelvic brim. The sigmoid traction is
reversed and the surgeon on the patient’s right can
identify the exact place to incise the right-sided per-
itoneum by a combination of air in the tissues and
displacement of the mesentery anteriorly. The swab
helps to protect the autonomic nerves at the level of
the pelvic brim by displacing the colonic mesentery
anteriorly. The right-sided peritoneum is incised
caudally to the pelvic brim and cranially towards
the root of the inferior mesenteric artery. At this
point, the surgeon on the patient’s left places the
left index finger behind the pedicle, with left thumb
anteriorly, palpating the vessel between index finger
and thumb. The peritoneal attachments are divided
and pre-aortic nerve structures mobilized away
from the right side of the pedicle by sharp dissec-
tion. The index finger is then advanced cranially on
the left side, parallel to the midline, where a window
will be identified above the origin of the inferior
mesenteric artery (IMA) between the aorta and the
inferior mesenteric vein (IMV) and ascending left
colic artery running side by side at this point. This
window is opened, and the autonomic nerves are
freed until the root of the IMA is clearly identified.
It is important to check that the left ureter has not
been elevated in this manoeuvre by visualizing the
structures to the left of the pedicle. Once the IMA
pedicle has been isolated, it is clamped, divided and
ligated approximately 2 cm from the aorta to reduce
injury to the pre-aortic nerves and to achieve a high
but not flush tie of the IMA (Figure 7.8).
For maximum length and mobility of the left
colon, the IMV has to be divided above its last
branch, at the inferior border of the pancreas, where
it disappears upwards to join the splenic vein. In
5–10 per cent of patients, a substantial branch of
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 112  Total mesorectal excision for rectal cancer
Figure 7.8. Ligation of the inferior mesenteric artery (large
arrow) and high ligation of the inferior mesenteric vein
(small arrow).
the superior mesenteric artery lies near the IMV
at this point, supplying part of the arterial blood
supply to the left colon. Judgement is required to
determine whether this vessel should be divided to
provide sufficient length or preserved if it is likely to
be important for colonic viability.
MOBILIZATION OF THE
MESORECTUM AND RECTUM
The pelvic dissection is oncologically one of the
most important stages of the operation. The sur-
geon must develop a mental picture of the exact
position and extent of the tumour, based on the
prior clinical and radiological assessment. The cir-
cumferential concepts of TME surgery are applied
to ensure clear margins on the resected specimen.
It is helpful to divide the descending colon well
above the cancer at this stage, a so-called ‘division
of convenience’ using a linear cutting stapler such
as a GIA 60 (Figure 7.9). This particularly facilitates
the posterior pelvic dissection.
The ‘division of convenience’ allows optimal
mobility of the top of the specimen and facilitates
HEBK001-C07_p103-123.indd 112
Figure 7.9. The colon has been divided using a linear
cutting stapler and the posterior plane is being developed
anterior to the superior hypogastric plexus and hypogastric
(presacral) nerves.
gentle opening of the perimesorectal planes by trac-
tion and counter-traction in any direction through-
out the pelvic dissection. Having divided the colon,
the small bowel and right transverse colon can be
packed away, upwards and to the right. Personal
preference is to place a large pack under the root
of the caecum wrapping the small bowel and place
a gauze roll beneath the root of the mesentery. An
extendable self-retaining retractor (we generally use
a Finochetti chest retractor with the largest retrac-
tor blades) then opens up the space and allows
excellent views into the top of the pelvis.
Posterior Dissection – Starting ‘Right’
The pelvic dissection for a rectal cancer is a dynam-
ic procedure and involves circumferential disection
commencing posteriorly, continuing laterally and
anterolaterally and then anteriorly, and constantly
moving the site of dissection rather than proceed-
ing too far at one site. The easiest place is commonly
posteriorly, and commencement in this area is cru-
cial. For clarity the dissection sites are covered sepa-
rately, although in reality it is a dynamic procedure
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 MOBILIZATION OF THE MESORECTUM AND RECTUM  113
requiring alteration in the placement and direction
of traction of the retractors. The ‘pedicle package’ –
the clue to the top of the ‘holy plane’ – involves the
key principle that dissection should proceed only
in the areolar tissue plane (the ‘holy plane’) within
(and thus sparing) the autonomic nerve plexuses,
the non-visceral presacral fat pad (when present),
the parietal side-wall fascia of the small pelvis, the
hypogastric plexus, the vesicles, and the prostate in
male patients and the vagina in female patients. All
of the dissection should be performed sharp with
diathermy or scissors under direct vision with good
light. Throughout, the dedicated assistants should
provide three-directional traction to open up the
planes for the operator: diathermy can be used
safely only when the areolar tissue is on stretch. The
overall procedure is lengthy and time-consuming
and requires prolonged attention to detail, as a
careful TME plus pouch-to-anus reconstruction
takes 3–5 h according to the detail of the patient’s
build.
Starting correctly involves three-directional trac-
tion on the colon and retroperitoneum to identify
the plane between the back of the pedicle package
and the gonadal vessels, ureter and pre-aortic sym-
pathetic nerves, all of which must be carefully pre-
served. The key to this phase is the recognition of
the shiny fascial-covered surface of the back of the
pedicle – like a tapering longitudinal sausage with
the inferior mesenteric vessels within. This must be
gently lifted forwards.
The avascular areolar tissue plane (mesorectal fas-
cia) that surrounds the mesorectum is identified. It
is worth remembering that the mesorectum resem-
bles a bilobed lipoma. The rectum is lifted gently
forwards from the bifurcation of the hypogastric
nerves, and dissection commences in the midline
using diathermy, aiming to minimize direct or
collateral heat damage to the nerves. Dissection is
extended downwards anterior to the curve of the
sacrum on the surface of the mesorectal fascia. Once
there is sufficient space, a St Marks rectal retractor
(one with integral illumination, if available, is opti-
mal) is introduced behind the specimen. This helps
to spread and ‘tent’ the hypogastric nerves and aids
identification. It is important to gently position
the retractor and apply firm but gentle pressure to
expose the mesorectal fascia and the layer of are-
olar tissue (sometimes called ‘angel hairs’) where
dissection should proceed. In this manoeuvre, the
HEBK001-C07_p103-123.indd 113
operator standing on the patient’s left and the first
assistant on the patient’s right have to position and
control the angulation and retraction force, aided by
the second assistant between the patient’s legs when
more forceful retraction is needed. It is important
to note that all four hands of the operator and first
assistant are needed for retraction and dissection,
and a suction device may be a useful retractor, in
addition to its role in removing smoke and fluid. It
is really only the operator and first assistant who can
clearly determine the correct angulation and direc-
tion of the retractors. The second assistant’s role is
predominantly supportive and to add force rather
than direction to the traction and counter-traction.
It is useful to wash out the pelvis on a regular basis;
personal preference is to use water with dilute liq-
uid proflavine (an antiseptic and cytocidal agent). In
this context, water rather than normal saline is opti-
mal, as it is hypotonic and therefore cytocidal. Addi-
tionally, the use of a clear solution helps to visualize
the tissue planes, unlike equally effective agents such
as povidone–iodine.
Dissection proceeds in the ‘angel hair’ and should
be predominantly from below upwards, allowing
the hypogastric nerves to drop away posterolateral-
ly. It is important to focus on circumferential mobi-
lization rather than proceed too far posteriorly at
this stage. Some dissection in the lateral and ante-
rior plane is recommended at this juncture.
Lateral Dissection
The lateral attachments are mobilized by extend-
ing the dissection plane forwards from the midline
posteriorly around the side-walls of the pelvis. It is
important to remember that the inferior hypogas-
tric plexuses (formed by the hypogastric nerves and
the pelvic parasympathetic nerves) curve forwards
tangentially around the surface of the mesorectum
in close proximity to it. The nervi erigentes (pel-
vic parasympathetic nerves on which male erection
depends) lie more posteriorly in the same plane as
the hypogastric nerves and should be visualized and
preserved, although it is all too easy to ‘tent up’ the
nerves and cut them at this point.
The nervi erigentes curve forwards from the sacral
foramina and converge like a fan to join the hypogas-
tric nerves and form the neurovascular bundles of
Walsh,4 as elegantly illustrated in Figure 7.10, adapted
11/02/13 3:51 PM
 114  Total mesorectal excision for rectal cancer

Dissection Anteriorly

The traditional approach in low anterior resection in

prostate male patients was to incise the peritoneal reflection
anteriorly, but a more satisfactory approach is to fol-
low the plane forwards, from behind, anterolaterally
neurovascular vesicle on both sides until the vesicles are visualized.
bundle A small swab may be placed on the anterior sur-
face of the specimen, and the plane immediately in
Denonvilliers’
denonvilliers’ front of Denonvilliers’ fascia is developed by sharp
fascia dissection in the midline anteriorly and then care-
fully extended laterally to meet the lateral dissection,
remembering that autonomic nerves converge to
form the neurovascular bundles at the outer edge of
Denonvilliers’ fascia (see Figure 7.11). Denonvilliers’
fascia marks the anterior extent of the ‘tumour pack-
age’ and lies like an apron anterior to the anterior
mesorectum, behind the vesicles, until it fuses pos-
teriorly with the posterior fascia of the prostate. For
this reason, Denonvilliers’ fascia must eventually be
the ‘holy plane’ divided by scissors or diathermy to access the lowest
Figure 7.10. Schematic outline of the mesorectum few centimetres of the anterior rectum. This should
and mesorectal fascia with the neurovascular bundles
anterolaterally in the male pelvis.

from Walsh’s approach to radical prostatic resection

for prostate cancer.
Thus, the nerves lie at the outer edges of Denon-
villiers’ fascia and are in danger at the 10 o’clock
Denonvilliers’
and 2 o’clock anterolateral positions, just behind fascia
the lateral edges of the seminal vesicles in the male.
More distally, they curve forwards out of danger.
As the lateral dissection moves deeper into the
pelvis, one or two middle rectal vessels may be
encountered and occasionally may have to be oc-
cluded by precise diathermy or ligation after appli-
cation of a slender curved artery forceps. There are
almost always some slender nerve branches at this
point, and it is usually these branches that form the
so-called ‘lateral ligament’. When medial traction
is applied, these branches will ‘tent’ the plexus; it
is important to divide them by sharp diathermy or
scissors dissection on the mesorectal surface. The
previously described clamping of the lateral liga-
ments is unnecessary and potentially injurious to
the pelvic nerves.
If bleeding is encountered, it is often wise to
place a gentle pack (personal preference is to use an Figure 7.11. Schematic view with rectum posteriorly. It is
adrenaline-soaked swab) and move the dissection the author’s preference to dissect along the dotted line
to another area, perhaps the other side or anteriorly. anterior to Denonvilliers’ fascia.

HEBK001-C07_p103-123.indd 114 11/02/13 3:51 PM

 MOBILIZATION OF THE MESORECTUM AND RECTUM  115
Figure 7.12. Total mesorectal excision in female patients.
be well beyond the distal edge of the cancer, except in
ultra-low resection of a distal rectal cancer.
Anterior dissection in female patients
Anterior dissection in female patients is gener-
ally more straightforward, provided the uterus has
been lifted well forward (Figure 7.12). One use-
ful manoeuvre is to place a strong figure-of-eight
suture through the apex of the uterus and suture
this to the lower end of the wound, which helps
considerably in uterine retraction. There is a con-
densation of fibrous tissue anteriorly, analogous to
Denonvilliers’ fascia in the male but almost always a
much more tenuous structure.
It is often difficult to find a precise avascular
plane behind the cervix and posterior fornix with-
out encountering bleeding from the venous plex-
us. Often the peritoneal reflection may adhere to
the posterior fornix. As in male patients, the plane
may be best approached by continuation of the
anterolateral dissection from the side-wall, thus
finding the relatively avascular plane between the
rectum and vagina. If bleeding occurs from the
vagina, attempts to control it may be futile until
the vagina is fully mobilized off the anterior rec-
tum, allowing the stretched venous plexus to col-
lapse down.
Additionally, provided the cancer resection per-
mits, the peritoneal incision may be made at the level
of the posterior fornix to facilitate entering into the
plane between the vagina and what is best termed
HEBK001-C07_p103-123.indd 115
the ‘rectogenital septum’ (the female equivalent of
the male Denonvilliers’ fascia). It is sometimes help-
ful to place a narrow retractor (e.g. narrow Kelly
retractor) or a moist ‘swab-on-a-stick’ in the vagina
to help identify the posterior fornix of the vagina
and find this plane.
Denonvilliers’ Fascia and the Anterior
Part of a Low Anterior Resection
There is ongoing controversy concerning the exact
origin of Denonvilliers’ fascia and some debate as to
whether it exists in female patients. Most now agree
that the term ‘rectogenital septum’ is more compre-
hensive and encompasses Denonvilliers’ fascia, and
that the most likely origin is two layers of perito-
neum partly or fully fused together and obliterating
what was once a peritoneal cavity extending to the
pelvic floor. In anterior resection, one has to divide
this layer from above to enter the plane between
the rectum and the prostate in male patients, as
the fascia fuses with the back of the prostate. The
upper part of the septum is usually adherent to
the anterior mesorectal fat of the middle third. In
female patients the middle third has a rather thin
and tenuous fatty layer between the rectum and
vagina, with the fascia often being scant and dif-
ficult to identify. The ‘rectogenital septum’ in male
patients is commonly a substantial rectangular or
trapezoidal layer, like a bib between the hindgut
behind and the vesicles and prostate in front. Just
as peritoneum is the integral surface of the ante-
rior aspect of the upper, intraperitoneal third of the
rectum, so the rectogenital septum ­(Denonvilliers’
fascia) is integral to the fatty anterior mesorectum
in the middle third in male patients.
Anterolateral Dissection
Connecting the lateral to the anterior plane is a
critical point in the dissection. It is usually best
to continue the dissection from posterior to ante-
rior, as the autonomic nerves will usually be visible
and the correct plane is just medial to the auto-
nomic bundles. There is a tendency to stray too far
­laterally with attendant risks of injury to the auto-
nomic nerves or troublesome bleeding from the
lateral pelvic side-wall vessels. Careful assessment
11/02/13 3:51 PM
 116  Total mesorectal excision for rectal cancer
and reassessment is essential at this point to access
the correct operative plane. The anterolateral
peritoneal and subperitoneal incisions are curved
medially towards the midline anteriorly to preserve
the autonomic nerve structures.
Deep Posterior Dissection
Posteriorly and posterolaterally, the areolar plane
is well defined around the globular expanding
bilobed mesorectum. A condensation of the fascia
called the rectosacral ligament (or Waldeyer’s fas-
cia) often presents a barrier to the surgeon poste-
riorly below the promontory. Just in front of the
rectosacral fascia (also referred to as the rectosac-
ral ligament), within the mesorectum, the superior
rectal vessels can often be seen through the back of
the mesorectal fascia, and around them cancerous
nodes are likely to be present, often only millime-
tres away. An intact shiny visceral fascia over these
must be jealously guarded and tearing avoided at
all costs. This poses one of the greatest dangers of
blunt manual extraction or of any haste or rough-
ness, since the rectosacral ligament may be stronger
than the surface fascia over the nodes. Thus, tear-
ing into the lymphatic field by the inserted hand
becomes a real risk and probably occurred often
in the past. Sharp dissection under direct vision is
crucial and good lighting is essential. Beyond this
area of attachment, the plane is easy to recognize,
except that the forward angulation demands strong
anterodistal retraction to facilitate direct visualiza-
tion. Understanding the importance of this forward
angulation is critical to mastering the traction and
counter-traction necessary in open, laparoscopic
and robotic TME.
A further reason to positively identify the ‘holy
plane’ posteriorly, in front of the presacral fat pad
(when present), is to avoid the risk of tearing thin-
walled presacral veins, which often have no valves
and can bleed prodigiously when cut or torn. Inju-
ry to these veins is much less likely if the correct
plane is followed and tearing is avoided; if they
are torn, a small pack and a considerable period of
anterior dissection away from them will provide
the safest way forward. The key to this dissection
is always to remain on the yellow mesorectal fascia
and to ­display the dissection plane by traction and
­counter-traction.
HEBK001-C07_p103-123.indd 116
Lateral Pelvic Dissection
This involves forward extension of the plane from
the back around to the sides, gently easing the
adherent hypogastric nerves laterally off the mes-
orectal surface under direct vision. The freedom to
lift the divided rectosigmoid forward often means
that the tangentially running hypogastric nerves are
first positively identified at this stage, the superior
hypogastric plexus itself only becoming obvious
proximal to the nerves after they have been dissect-
ed away from the mesorectal surface on each side.
The superior hypogastric plexus may have been
ensheathed by fatty tissue and not immediately rec-
ognized as a nerve bifurcation.
The ‘Lateral Ligament’ Area
The so-called ‘lateral ligaments’ are now generally
acknowledged not to be true ligaments and appear
to be attachments between the rectum and pelvic
side-wall by small nerves going directly from the pel-
vic plexus to the rectum, often accompanied by tiny
arteries and veins. This particular point of adherence
in the distal anterolateral sector is one of the most
complex and difficult areas in a TME operation.
The area is approached by following the ‘holy
plane’ down towards the vesicles in male patients,
with the expanding plexiform band of inferior
hypogastric plexus outside it but increasingly adher-
ent to it. In essence, there is no actual ligament, but
there is an area of adherence between mesorectum
medially and plexus laterally: small branches of
nerves and vessels penetrate through at this point,
but none generally reaches more than 1–2 mm in
diameter. The key nerves entering this flattened
band from above are largely sympathetic hypogas-
tric nerves curving distally from the superior plex-
uses and more distally the erigent parasympathetic
nerves coming forwards to it from behind. These
arise from the front of the roots of the sacral plexus
(especially S3, out of sight behind the parietal side-
wall fascia). This fascia is quite robust laterally, and
the surgeon will note that they usually cannot even
see the internal iliac vessels, which are outside and
positioned laterally. Posteriorly, these erigent pillars
from the nerve roots around S3 curve forwards out-
side the parietal fascia, but medial to the branches
of the internal iliac vessels.
11/02/13 3:51 PM

A little way behind the vesicles in male patients,
the erigent pillars pierce the fascia to join the infe-
rior hypogastric plexus and often contribute nerve
branches to the mesorectum and rectum. These
neural T-junctions are the nearest structures to ‘lat-
eral ligaments’ that the most careful surgeon will
find with precise dissection. On occasions, there
is a true middle rectal artery of substantial size
at this point, but this is much less frequent than
reported and may be no more than in the region
of 20 per cent or so, and then only on one side. We
believe that in the past, what the surgeon thought
to be a middle rectal artery was most often a lat-
eral intramesorectal artery, and the so-called ‘stalk’
being divided represented a ‘coning in’ to the mes-
orectum. Alternatively, dissection too laterally will
result in damage to a pelvic side-wall vessel.
Careful dissection between the mesorectum and
the inferior hypogastric plexus may result in bleed-
ing but usually nothing more than a tiny vessel that
requires no more than a touch of diathermy. Thus,
the clamp and cut routine generally implied a poor
quality of dissection and damaged nerves, and left
a substantial residue of dangerous tissue – probably
all a part of the 30–40 per cent local recurrence rate
that was once common.
A more distal vessel from the prostatic branch in
male patients or from the pelvic floor is often found
later, and lower down, where it can cause troublesome
bleeding. It is likely that the minimal nature of a true
middle rectal blood supply also implies a minimal
lymphatic component, accounting for the relatively
few patients with spread to the pelvic side-wall nodes.3
With regard to the so-called ‘lateral ligament’,
the surgeon should generally attempt to dissect at
this point of adherence precisely between the out-
er aspect of the mesorectum and the triangulated
neural band of nerve plexus, which should be left
intact. This technique can be dubbed ‘mesorectal
fat surface dissection’, because no actual loose are-
olar tissue exists in those areas where mesorectum
and plexus are adherent. The final specimen will
often lack the shiny fascial covering over this area.
Deep Anterior Dissection
As outlined above, the key structure anteriorly is
Denonvilliers’ fascia in male patients and the rec-
togenital septum equivalent in female patients. In
HEBK001-C07_p103-123.indd 117
EXTENDED RESECTION IN SPECIAL CASES   117
male patients, as one works distally, there comes a
point where the fascia must be divided transversely,
as it becomes adherent to the posterior capsule of
the prostate. Particular care is necessary during this
step to avoid damage to the neurovascular bundles
(of Walsh) that constitute the distal condensation of
the inferior hypogastric plexuses, joined by numerous
veins and small arteries, hence the title ‘neurovascular’.
In a low anterior tumour in male patients, this
can be critical: it is essential to avoid exposing
malignant tissue on the front of the specimen at
the very point where the nerves are curving acutely
medially. Since they are often impossible to see in
open surgery because of forward angulation behind
the vesicles, bladder and prostate, they are in partic-
ular danger. In addition, surgeons who ‘take a slice
off the back of the prostate’ are highly likely to cause
impotence because of the close relationship of the
neurovascular bundles to the back of the prostate.
Hand in hand with this dissection anteriorly goes
the development of the lateral side-wall dissection.
The parasympathetic erigent nerves form poster-
oanterior lateral pillars on the pelvic side-wall. ­Cadaver
dissections have led us all to be taught that the pelvic
parasympathetic outflow is tripartite S2–3–4, but
to the surgeon there is no doubt that a recognizable
landmark is often a single or bifid pillar comprising
a nerve root arising from the front of the S3 compo-
nent of the main sacral plexus, which is out of sight
posteriorly. The pillar-like appearance is due in part
to the forcible forward traction on the prostate, vagi-
na and bladder to see the structures during an open
operation; this tends to bow the nerves medially and
thus make them stand out. This retraction does not
occur to the same extent in a laparoscopic operation,
which may account for some of the reported higher
incidence of nerve damage at laparoscopic rectal can-
cer surgery. These pillars and the hypogastric plex-
uses curve medially towards the back of the prostate
in male patients, where they form the neurovascular
bundles, which taper towards the urethra at the apex
of the prostate. Here they become the erectile nerves
of the corpora cavernosa or cavernous nerves.
EXTENDED RESECTION
IN SPECIAL CASES
With current optimal preoperative staging, it is
uncommon to unexpectedly find a rectal cancer at
11/02/13 3:51 PM
 118  Total mesorectal excision for rectal cancer
operation that extends into adjacent organs. It is
pertinent to be aware that although attachment to
or invasion of an adjacent organ may be an inflam-
matory adhesion, in approximately half of patients
cancer invasion is present. Rupture of a malignant
adhesion will almost certainly result in tumour
spillage and dissemination or local recurrence.
Consequently, if feasible, it is prudent to resect an
adjacent, adherent structure rather than gamble on
the adhesion being benign.
Uterus and Vagina
Involvement of the vagina and uterus is usu-
ally detected at preoperative imaging and vaginal
examination before surgery. A large fixed cancer,
even with neoadjuvant chemoradiotherapy, is best
removed by en-bloc resection of the uterus and rec-
tum and as much as is needed of the posterior vagi-
nal wall to clear the tumour safely. The vagina may
be closed primarily in most such cases, but if the
defect is large, particularly in a sexually active wom-
an, reconstruction using a musculocutaneous flap
may be needed. The need for this should have been
anticipated, and appropriate assistance (perhaps by
a plastic surgeon) and resources should be available.
Seminal Vesicles
Involvement of the vesicles on one or both sides
may be managed by dissection anterior to the
vesicles, removing them en bloc with the rectum.
The ureters are at risk and should be identified
and preserved, and it may be prudent to consider
preoperative ureteric stenting to facilitate identifi-
cation. Additionally, the neurovascular bundles are
at particular risk, and problems with urinary and
sexual dysfunction may ensue.
Prostate
It is possible, although technically difficult, to
remove a part of the prostate involved by a rectal
cancer. Major prostatic involvement may require
pelvic exenteration, however, or, in selected patients,
a nerve-preserving prostatectomy. Modern MRI
imaging should predict this eventuality, and the
HEBK001-C07_p103-123.indd 118
advice and assistance of an experienced urologist
should be sought.
Ureters
The ureters may be involved in rectosigmoid or
colonic cancers but are seldom involved in tumour
of the mid- or low rectum, unless the tumour is very
advanced. In all complex pelvic surgery, however, it is
always prudent to visualize, and in most cases mobi-
lize, the ureters. It is safe to divide the tissues anterior
to the ureteric tunnels in male and female patients as
the ureters are anterior to the pelvic plexuses and are
crossed only by the vas deferens in males and the uter-
ine vessels in females. A locally advanced tumour may
invade the distal ureter and require en-bloc resection.
Depending on the extent of the ureteric defect and
the height of the ureteric resection, it may be possible
to perform a scalloped end-to-end anastomosis over
a ureteric stent or to reimplant the proximal end into
the bladder or the opposite ureter. Again, urological
assistance is strongly recommended.
Bladder
Rectal cancer involving the bladder is usually pre-
dicted by preoperative pelvic MRI, and neoadju-
vant chemoradiotherapy is generally indicated.
Cystoscopy is recommended as part of the work-up
to try to determine the site of involvement relative
to the ureters. The operative strategy for rectal can-
cer involving the bladder requires consultation with
a urologist and varies from partial cystectomy, to
excising a disc of the involved bladder en bloc with
the rectum (this will almost always be an upper
rectal cancer in this scenario), to total cystectomy
by pelvic exenteration, particularly if the trigone is
involved. Bladder involvement is much more com-
mon in male patients. In female patients, the uterus
and vagina intervene between the rectum and blad-
der, acting as a barrier to bladder invasion.
Inferior Hypogastric and
Pelvic Plexuses
Even though the focus in TME surgery is on iden-
tification and preservation of these nerves, a locally
11/02/13 3:51 PM
 DISSECTION OF THE MOST DISTAL MESORECTUM   119
advanced tumour, adherent to the pelvic side-wall,
may require nerve resection. The perivascular plane
outside the nerves along the aorta and major ves-
sels may be developed and followed. Depending on
the site and extent of the tumour, it may be possible
to limit dissection and nerve resection to one side.
Bladder and sexual function is likely to be impaired,
depending on the particular nerves excised.
Pelvic Side-Wall Nodal Involvement
There is a wide variation in the reported incidence
and clinical significance of pelvic side-wall involve-
ment. Increasingly, there is general agreement that
lateral nodal involvement is associated mainly with
low rectal cancer, is indicative of tumours with a
worse prognosis, and can often be predicted by pel-
vic imaging.3 The details are outlined in Chapter 14.
DISSECTION OF THE MOST
DISTAL MESORECTUM
The anatomy of the position of the mesorectal
package in relationship to the pelvic floor becomes
difficult for the surgeon to grasp from above
because of its inaccessibility behind the vesicles and
prostate in male patients and behind the vagina in
female patients. The situation is complicated fur-
ther by the fact that the levators are like a funnel in
continuity with the tube of the external sphincter
distally. Conceptually, and because of the distor-
tion introduced by upward traction, surgeons tend
to think of the pelvic floor as being much flatter
than it is in vivo, especially if an assistant applies
upward pressure on the perineum. If one doubts
this, a careful look at the layers on a coronal MRI
scan will make it evident. A clear three-dimension-
al perception of the now globular bilobed mesorec-
tum in the depth of the pelvis and the surrounding
neural lamella is the most elusive and challenging
conceptual acquisition for the aspiring rectal can-
cer surgeon.
Careful pursuit of the plane at this level eventually
liberates the mesorectal package and takes the opera-
tor down to a clean muscle tube. Although crossed
by a few small arteries and veins from the puborec-
tal sling and some slips of sphincter muscle, the ‘holy
plane’ here becomes the intersphincteric plane, which
HEBK001-C07_p103-123.indd 119
is familiar to proctologists from below – a tube of red
skeletal muscle outside a tube of whiter smooth mus-
cle within (the internal sphincter).
Partial Mesorectal Excision (High
Anterior Resection and Mesorectal
Transection)
Tumours of the upper rectum (lower edge 11–15 cm
from the anal verge) may not require TME and may
be optimally managed by mesorectal transection
5 cm below the lower edge of the tumour. The char-
acterization of rectal cancer into high, mid- and low
has traditionally been measured from the anal verge
in conscious patients using a rigid sigmoidoscope.
It is worth documenting the height at MRI; indeed,
after much debate, a new definition of low rectal
cancer is emerging as a tumour with its distal mar-
gin at or below the level of origin of the levators on
the pelvic side-wall (see www.lorec.nhs.uk).
Rectal cancer heights measured under anaes-
thesia need to be from the dentate line, since the
external sphincter dilates and retracts (add about
1.5 cm). Care is necessary: any instrument can push
a mobile tumour upwards, and flexible instru-
ments often give falsely high measurements. With
these qualifications, it can be said that, in our view,
most cancers with the lower edge at or below 12 cm
should have TME as the key component of a radi-
cal cancer operation because the mesorectum is the
primary field of lymphovascular spread. The deci-
sion as to whether the smaller partial mesorectal
excision is adequate, however, is confirmed after the
mobilization has been completed to the point where
the mesorectum must be liberated from the adher-
ent inferior hypogastric plexus – the region usually
referred to as the ‘lateral ligament’. It has long been
convention and a very sound rule, borrowed from
­German surgical practice, that a minimum of 5 cm
of mesentery should always be excised both proxi-
mal and distal to any colorectal cancer. Although
muscle tube margin may safely be reduced to 1 cm
in the interest of anal conservation, we have always
believed that if less than a TME is contemplated, a
minimum of 5 cm of mesorectum distal to the low-
er edge of the cancer must be dissected in the per-
imesorectal (‘holy’) plane. If, therefore, after initial
mobilization there is a clear 5 cm of mesorectum,
then tapering into the mesentery, in the interest of
11/02/13 3:51 PM
 120  Total mesorectal excision for rectal cancer

making a more minor operation and a higher anas-

tomosis, becomes acceptable. An anastomosis in a
patient who has mesorectal transection, provided it
is airtight, is less likely to leak than after a TME. In
this case, selected patients may avoid a temporary
stoma.

Management of the Anorectum Distal

to the Cancer: Stapling Techniques,
Distal Washout and Anastomosis
In more than 90 per cent of rectal cancers, it is tech-
nically feasible, although not necessarily optimal in
terms of future function, to extend the dissection
down to a clean muscle tube where a cross-clamp
may be applied with a finger-and-thumb clearance
beyond the lowest edge of the cancer. This is a dif-
ficult and challenging moment requiring both skill
and experience. We have developed a preference for
the use of the linear stapler in place of the right- Figure 7.13. Schematic drawing of a linear stapler applied
angled clamp (the Moran triple stapling technique). across the anorectal tube below the cancer.
The first TA-45, TA-30 (Covidien) staple line seals
the muscle tube (Figure 7.13) so that the anorectal This is usually, although not invariably, the micro-
lumen beyond can be washed out with water or a scopic edge. Downward spread along the muscle
tumoricidal solution (Figure 7.14). tube is not a significant factor in recurrence: a 2 cm
For very low tumours we have modified the tech- clearance is more than adequate, and 1 cm plus the
nique and now leave the first TA-30 closed and fired ‘doughnut’ is acceptable when the tumour is very
and in place, washout below it and place a second low and survival of the anal sphincters depends on
TA-30 below the first, across the washed muscle such a narrow margin.
tube (Figure 7.15). The bowel is sectioned with a
scalpel between the two TA-30 guns.
A proctoscope is introduced into the anal canal,
and the lumen below the staple line is irrigated with
repeated infusions using a 50 mL bladder syringe
or through a catheter irrigation system. Water (not
saline), povidone–iodine or dilute proflavine are
recommended.
The risk of incorporating viable exfoliated
intraluminal cells in the second staple line is thus
eliminated and a second TA-45 or TA-30 is fired
through the washed bowel while the anatomy is
distorted by upward traction on the first (pathol-
ogist’s) stapler. This process, in our view, justifies
the cost of a second stapler because of the greater
security against spillage of potentially malignant
bowel contents. Only this washed staple line
remains within the patient. Figure 7.14. Schematic drawing of washout below an
The first of these two linear staple lines should be occlusive staple to remove any debris, which may contain
safely clear of the palpable distal edge of the cancer. viable tumour cells.

HEBK001-C07_p103-123.indd 120 11/02/13 3:51 PM

 DISSECTION OF THE MOST DISTAL MESORECTUM   121
Figure 7.15. Modified ‘Triple stapling technique’. The washed
muscle tube is sectioned between the two linear staplers. The
muscle tube is divided on the proximal surface of the distal
stapler (Moran triple stapling).
The rectal cancer specimen is now removed. Care-
ful examination of the bowel end in the upper sta-
pler will confirm clearance: frozen section is general-
ly unnecessary. If there is doubt about clearance, the
staples may be removed and the lumen inspected.
Only after checking this should the distal (patient’s)
stapler be removed. In the occasional case where the
clearance is marginal, the distal stapler can be pulled
up hard and a further linear stapler applied and fired
beyond the distal one, although clearly this is less per-
fect than first-time clearance of the cancer.
If there are no concerns with clearance after
inspection (and removal of the staples if necessary),
the distal linear stapler is removed, leaving a trans-
verse staple line across the anorectal muscle tube.
The pelvic cavity is washed copiously and
inspected for bleeding. Haemostasis is secured with
carefully applied diathermy or suturing if necessary.
HEBK001-C07_p103-123.indd 121
For troublesome presacral, pelvic side-wall or other
bothersome bleeding, a haemostatic agent such as
Tachosil® may be helpful. Another strategy to keep
in mind is that rather than repeated futile attempts
at diathermy or suturing, packing the pelvis for
10–15 min will usually arrest bleeding.
Neorectal Reservoir
When TME has been performed and a coloanal
anastomosis is required, a neorectal reservoir pro-
vides better functional outcome than a straight
colonic anastomosis. Whatever technique is used,
adequate length of colon from the splenic flex-
ure mobilization is essential for the pouch to lie
without tension in the hollow of the sacrum. For
a reservoir, a side-to-end (side of colon to end of
anorectum) anastomosis is acceptable and easiest
to construct. Alternatives include construction of a
colonic J-pouch or a coloplasty.
For a side-to-end anastomosis, approximately half
of the colonic staple line is excised and the lumen
washed out. This allows assessment of the distal
colonic blood supply and inspection of the mucosa.
An appropriately sized circular stapler is select-
ed (28–31 mm head is optimal), and the head is
detached. The detached head of the gun is inserted
into the lumen spike first, and the spike is brought
out through the antimesenteric border, halfway
between the taenia coli, approximately 4 cm from
the distal colonic end. The defect in the staple line
is closed with interrupted sutures. We tend to invert
the remaining staple line as well.
The side-to-end technique provides a flat surface
for the proximal part of the anastomosis and leaves
room for the thicker anorectal end.
Several variations of pouch construction are
available. Typically a GIA-60 is inserted via a colos-
tomy 5 cm from the end of the fully mobilized colon
to create a J-pouch.
The CEEA-31 staple gun anvil is inserted into the
same colostomy, which is purse-stringed around
the shaft with 00 Surgipro.
Circular Stapled Anastomosis
The anorectal remnant is palpated from between
the legs. The anal canal may have to be dilated
11/02/13 3:52 PM
 122  Total mesorectal excision for rectal cancer

gently to accommodate the lubricated circular sta-

ple gun. Relaxation of the anal sphincter by per-
anal application of glyceryl trinitrate (GTN) cream
applied 30–60 min before or sublingual GTN spray
applied 5 min before may facilitate introduction of
the stapler by relaxing the internal sphincter. The
body of the circular stapler, usually the CEEA-31, is
inserted from below transanally. It is essential with
ultra-low anastomoses to be certain that only the
internal sphincter is purse-stringed into the instru-
ment. To this end, it must be confirmed from above
that only one thickness of muscle can be felt around
the periphery of the cartridge. Care must be taken
not to disrupt the transverse staple line, and the
abdominal surgeon may have to bimanually assist
in this step to ensure safe placement. A St Mark’s
retractor helps to visualize the anorectal stump and
anteriorly retract the vesicles and prostate in male
patients and the vagina in female patients.
Once the circular ring of the gun is visible clearly
through the bowel wall, the gun is opened and the
protruding spike guided through the bowel, ideally
just behind the linear staple line. The anvil (head)
of the gun in the proximal bowel is brought down,
engaged with the shaft. The gun is closed slowly
until the tissues are in apposition, as seen on the
tissue indicator mechanism on the gun shaft (see
Figure 7.16).
At this point, it is mandatory to check the align-
ment of the proximal colon (including the trans-
verse colon) to ensure there is not a 3608 twist of
the colonic mesentery before firing the stapler. Figure 7.16. Side- (of the colon) to-end anastomosis using
The circular stapler is fired according to the a circular stapling gun.
manufacturer’s instructions. A delay of a minute or
so before opening the gun according to the manu- haematoma in the hollow of the sacrum, which may
facturer’s instructions is said to reduce the risk of become infected, form an abscess, and point into the
staple line haemorrhage. bowel at or near the anastomosis, thus creating a late
The doughnuts are inspected for intactness of leak 10–20 days later.
the tissue rings. If there is concern about tumour
clearance in a low rectal cancer, the distal doughnut
should be sent for histology. Defunctioning a Low Anastomosis
The anastomosis is gently palpated for integrity
and can be air-tested by filling the pelvic cavity Even if the anastomosis is airtight, consideration
with water and insufflating air via the anal canal should be given to temporarily defunctioning all
using a bladder syringe. If an air leak is identified, coloanal anastomoses after TME. A randomized tri-
it may be possible to repair it with interrupted al in 2009 reported a 28 per cent leak rate in patients
sutures, if necessary by a transanal approach. after TME without a loop stoma compared with 10
Two low-suction Abdovac drains are used for 48 h, per cent in patients with a stoma.5
unless there is copious drainage, when they may Factors that have been reported by many groups
need to be left for longer. The objective is to avoid to increase the risks of anastomotic leakage are

HEBK001-C07_p103-123.indd 122 11/02/13 3:52 PM


height of the anastomosis from the anal verge (par-
ticularly below 5 cm, which includes all patients
who have had a TME), male patients, preoperative
chemoradiotherapy, and intraoperative techni-
cal factors such as major bleeding and absence of
a loop stoma. There is little to choose between a
defunctioning loop transverse colostomy and loop
ileostomy, although an ileostomy has the added
risks of a high-output stoma and probably more
adhesional obstruction risks in the longer term.
Unquestionably, a loop stoma reduces the conse-
quences of a leak and the need for emergency sur-
gery. If the recovery is uneventful, the stoma may be
closed 6–8 weeks later after a water-soluble enema
and rectal palpation to check there is no leak and to
dilate up any slight narrowing, which is quite com-
mon in the defunctioned anastomosis.
If a temporary stoma has not been placed and
there are concerns in the postoperative period,
an anastomotic leak should be sought by a rec-
tal contrast study (often performed in combina-
tion with an abdominal and pelvic CT scan). If a
leak is detected, the patient should have immedi-
ate broad-spectrum antibiotics while being pre-
pared for emergency reoperation surgery, which
will need a stoma. On occasion, it is possible to
salvage the anastomosis by a combination of a
proximal loop colostomy, distal washout of the
downstream colon and a pelvic drain. In some
patients, however, anastomotic excision with an
end stoma is required.
Conclusion
Rectal adenocarcinoma is a common cancer and
is curable by surgery alone in most cases. Recent
advances in pelvic MRI, adoption of the surgical
concepts of total mesorectal excision, and ­excellent
mechanical stapling instruments have revolution-
ized the management and outcomes of this techni-
cally challenging but eminently curable cancer.
References
1. Moran BJ. Stapling instruments for intestinal anastomo-
sis in colorectal surgery. Br J Surg 1996; 83: 902–9.
2. Karanjia ND, Schache DJ, North WR, et al. ‘Close
shave’ in anterior resection. Br J Surg 1990; 77: 510.
HEBK001-C07_p103-123.indd 123
FURTHER READING  123
3. Yano H, Moran B. The incidence of lateral pelvic
side-wall nodal involvement in low rectal cancer may
be similar in Japan and the West. Br J Surg 2008; 95:
33–49.
4. Walsh PC, Schiegel PN. Radical pelvic surgery with
preservation of sexual function. Ann Surg 1988; 208:
391–400.
5. Matthiessen P, Hallböök O, Rutegård J, Simert G,
Sjödahl R. Defunctioning stoma reduces symptomatic
anastomotic leakage after low anterior resection of the
rectum for cancer: a randomized multicenter trial. Ann
Surg 2007; 246: 207–14.
FURTHER READING
Birbeck K, Macklin C, Tiffen N et al. Rates of circumferen-
tial resection margin involvement vary between sur-
geons and predict outcomes in rectal cancer surgery.
Ann Surg 2002; 235: 449–57.
Daniels IR, Fisher SE, Heald RJ, Moran BJ. Accurate
staging, selective pre-operative therapy and optimal
surgery improves outcome in rectal cancer surgery:
a review of the recent evidence. Colorectal Dis 2007;
9: 290–301.
Dukes CE. The classification of cancer of the rectum.
J Pathol Bacteriol 1932; 35: 323.
Edwards DP, Leppington-Clark A, Sexton R, Heald RJ, Moran
BJ. Stoma related complications are more frequent after
transverse colostomy than loop ileostomy: a randomized
controlled trial. Br J Surg 2001; 88: 360–63.
Heald RJ, Husband EM, Ryall RDH. The mesorectum in
rectal cancer surgery: the clue to pelvic recurrence?
Br J Surg 1982; 69: 613–6.
Heald RJ. The ‘holy plane’ of rectal cancer. J R Soc Med
1988; 81: 503.
Heald RJ, Moran BJ, Ryall RDH, et al. The Basingstoke
experience of total mesorectal excision 1978–1997.
Arch Surg 1998; 133: 894.
Mercury Study Group. Diagnostic accuracy of pre-­
operative magnetic imaging in predicting curative
resection of rectal cancer; prospective observational
study. BMJ 2006; 333: 779–84.
MacFarlane JK, Ryall RD, Heald RJ. Mesorectal excision
for rectal cancer. Lancet 1993; 341: 457.
Moran BJ, Docherty A, Finnis D. Novel stapling technique
to facilitate low anterior resection for rectal cancer.
Br J Surg 1994; 81: 1230.
Quirke P, Durdey P, Dixon MF, et al. Local recurrence of
rectal adenocarcinoma due to inadequate surgical
resection: histopathological study of lateral tumour
spread and surgical excision. Lancet 1986; 2: 996.
Quinlan DM, Epstein JL, Careter BS, Walsh PC. Sexual
function following radical prostatectomy: influence of
preservation of neurovascular bundles. J Urol 1991;
145: 998–1002.
11/02/13 3:52 PM

Abdominoperineal excision
of the rectum
TorbjÖrn Holm
Introduction
The earliest surgical approaches to rectal cancer
were via the perineum, and the techniques used
were exclusively extraperitoneal. The intraoperative
and postoperative mortality was high, the postop-
erative functional results were extremely poor, and
the local recurrence rate ranged up to 90 per cent.
An important step in the development of the sur-
gical treatment for rectal cancer was taken by W.
Ernest Miles, a surgeon at St Mark’s Hospital in
London, who on 19 December 1908 in the Lancet
published a paper entitled ‘A method of perform-
ing abdomino-perineal excision for carcinoma
of the rectum and of the terminal portion of the
pelvic colon’.1 In Miles’ original description of the
procedure, the rectum was bluntly mobilized down
to the sacrococcygeal articulation posteriorly, to the
prostate anteriorly and to the upper surface of the
levator ani laterally. A colostomy was brought out
and the abdominal wall was closed. The patient was
then turned over and placed in the right lateral and
semiprone position. The perineal part of the opera-
tion included a wide excision of skin and fat, and
Miles emphasized that the levator muscles should
be divided ‘as far outwards as their origin from the
white line so as to include the lateral zone of spread’.
The specimen was brought out through the peri-
neum and the skin was closed over two drains.
HEBK001-C08_p124-139.indd 124
8
This paper had an enormous impact on the sur-
gical community, and ‘Miles’ operation’ became the
gold standard procedure for all rectal carcinomas for
many decades. The concept of removing the entire
rectum and the anus in all patients with rectal can-
cer gradually changed with time, however, and the
increasing experience with bowel reconstruction,
including the development of stapling instruments,
led to the new concept of anterior resection and low
anterior resection, which became the standard proce-
dures for tumours in the upper and middle rectum.2–6
For tumours in the lower rectum, most surgeons
continued to perform abdominoperineal excision
(APE), although the extensive perineal approach
described by Miles was more or less forgotten and
the synchronous combined APE was introduced as
a feasible procedure, which became popular and
gained widespread use in the treatment of low rectal
cancer.7 During the synchronous combined opera-
tion, the perineal part is carried out simultaneously
with the pelvic part of the abdominal procedure,
with the patient in the supine lithotomy or Lloyd
Davies position. The rectum with its mesorectum
is first mobilized down to the pelvic floor; the peri-
neal surgeon then enters the pelvic cavity just in
front of the coccyx, the levator muscles are divided
on both sides, and the rectum is dissected off the
prostate or the vagina and the specimen delivered
through the perineum.
08/02/13 5:54 PM
 PROBLEMS ASSOCIATED WITH CONVENTIONAL SYNCHRONOUS COMBINED  125
Despite the gradual improvements in rectal cancer
treatment during the twentieth century, local control
remained a major problem after surgery, with local
recurrence rates of up to 50 per cent after potentially
curative resections.8 Therefore, preoperative radio-
therapy was evaluated in several randomized trials
during the 1980s; it was shown to reduce the local
recurrence rate by 50 per cent and also to improve
cancer specific survival. It was with the develop-
ment of total mesorectal excision (TME), however,
as described by Bill Heald, that the picture changed
dramatically.9,10 The TME technique for rectal can-
cer resection was introduced in many countries
over the past 15–20 years, and subsequently the
results with regard to local control and cancer sur-
vival have improved significantly. Local recurrence
rates are now reported to be less than 10 per cent
in population-based studies.11–13 The acknowledge-
ment of TME as the standard surgical technique in
the treatment of rectal cancer has resulted not only in
improved local control but also in increasing rates of
sphincter-saving procedures and improved survival.
Therefore, since the mid-1990s, teaching in rectal
cancer surgery has focused mainly on the operative
technique of TME and anterior resection. Although
the technique used for the abdominal part of APE
was modified along the lines of TME, little attention
was given to the perineal part of this procedure. Thus,
most surgeons adopted the technique of sharp dissec-
tion under direct vision outside the mesorectal fascia
down to the pelvic floor, with the aim to save auto-
nomic nerves and to create a perfect specimen with
an intact mesorectal fascia. The perineal part, how-
ever, has often been completed in the conventional
way, with dissection outside the external sphincter
and with the division of the levator muscles close to
the rectal wall. With the patient in the supine lithoto-
my position, it is difficult to achieve an optimal view,
especially anteriorly (in the front), and therefore parts
of the perineal dissection are often done with blunt
dissection when this approach is used.
PROBLEMS ASSOCIATED WITH
CONVENTIONAL SYNCHRONOUS
COMBINED ABDOMINOPERINEAL
EXCISION
In recent years, several authors have acknowledged
the fact that local control and survival after APE
HEBK001-C08_p124-139.indd 125
have not improved to the same degree as that seen
after anterior resection. In one study based on 561
patients in Leeds in the UK, it was reported that
compared with patients who had an anterior resec-
tion during the same time period, patients under-
going APE had a higher local failure rate (22.3 per
cent v. 13.5 per cent) and poorer survival (52.3 per
cent v. 65.8 per cent).14
In another paper, based on data from five differ-
ent European trials, it was reported that the APE
procedure was associated with an increased risk of
circumferential resection margin (CRM) involve-
ment, an increased local recurrence rate and a
decreased cancer specific survival.15
The difference in oncological results between the
two procedures may be explained by several factors,
including anatomical difficulties and the surgical
technique associated with standard APE surgery.
In the lower rectum, the surrounding mesorectum
is reduced in size and disappears at the top of the
sphincters. Below this level, the sphincter muscle
forms the CRM. As mentioned above, the abdomi-
nal dissection during a conventional synchronous
combined APE is often carried out along the mes-
orectum, all the way down to the pelvic floor and the
top of the puborectalis muscle, with the mesorectum
being mobilized off the levator muscles. The peri-
neal dissection then follows the external sphincter to
meet the pelvic dissection at the top of the anal canal
(Figure 8.1a). With this technique, the retrieved
specimen often has a typical ‘waist’ at 3–5 cm from
the distal end, corresponding to the top of the exter-
nal sphincter at the level of the puborectalis muscle
and the lowest part of the mesorectum (Figure 8.1b).
This inwards coning at the pelvic floor carries
the dissection close to the rectal wall, and several
studies have reported higher rates of bowel perfo-
ration and tumour involvement of CRM after APE
compared with after anterior resection. Nagtegaal
and colleagues assessed 846 anterior resection
specimens and 373 APE specimens from the Dutch
TME trial. They found that the plane of resection
was within the sphincter muscle, the submucosa
or lumen in more than a third of the APE cases
and was on the sphincter muscles in the remain-
ing cases. This resulted in a positive CRM rate of
30.4 per cent after APE versus 10.7 per cent after
anterior resection, and a perforation rate of 13.7
per cent after APE versus 2.5 per cent after ­anterior
­resection.16 Similarly, population-based reports
08/02/13 5:54 PM
 126  Abdominoperineal excision of the rectum
Levator ani
Obturator internus
Ischioanal fossa
External sphincter
Internal sphincter
from Sweden, Norway and the Netherlands have
shown a threefold increase in perforation rates after
APE compared with anterior resection (14–15 per
cent v. 3–4 per cent).17
Thus, the differences in oncological outcome
between the conventional type of APE and anterior
resection may be explained to a substantial part by
the increased risk of tumour-involved margins and
inadvertent bowel perforations, as both of these
factors are significantly related to local control and
survival.
With the development of TME, leading to sub-
stantially improved results after anterior resection,
many surgeons have advocated low or ultra-low
HEBK001-C08_p124-139.indd 126
Figure 8.1a. The pelvic dissection
in a conventional synchronous
combined APE is carried along
outside the mesorectal fascia down
to the top of the anal canal (blue
line) and the perineal dissection is
carried along the external sphincter
(red line). The two dissection planes
meet at the level of the puborectal
muscle, which creates a waist on
the specimen.
Figure 8.1b. Photograph showing a
fresh specimen after a conventional
APE, with the typical waist at the level
of the puborectal muscle.
anterior resection, even for tumours of the lower
rectum. It has also been shown that these proce-
dures are feasible and oncologically safe, provided
the tumour can be removed with a clear distal and
circumferential margin. In dedicated and highly
specialized centres adopting intersphincteric ante-
rior resection for appropriate cases, the overall APE
rate may be below ten per cent.
On the other hand, the functional results after an
ultra-low anterior resection may be poor, especially
if the patient has received preoperative radioche-
motherapy.18 In patients with a preoperative history
of gas or faecal incontinence, careful counselling is
therefore mandatory and information should be
08/02/13 5:54 PM

100
90
80
70
60
Figure 8.2. Graph from 50 LAR
the Swedish Rectal Cancer 40
Registry showing the
30
proportion of patients, with
rectal cancer below 6 cm, 20
operated on with APE, AR 10
or Hartmann’s procedure, 0
annually since 1995. 1995 1997
given about the risk of a poor functional outcome
after an anterior resection. In such patients, a per-
manent stoma may be preferable.
If the tumour in the lower rectum is more
advanced, growing close to or into the distal mes-
orectal fascia, the levator muscle or the external
sphincter and thereby threatens the potential cir-
cumferential resection margin, it may not be pos-
sible to perform a safe anterior resection; in these
cases, an APE is necessary. The decision on when
to recommend an APE is therefore related to the
patient and the tumour characteristics. Since such
variables are interpreted differently between differ-
ent surgeons, the rate of APE varies greatly between
individual surgeons and between different institu-
tions. Morris and colleagues reported that the rate
of APE varied from 8.5 per cent to 52.6 per cent
between different English hospitals.19 In Sweden,
the rate of APE for low rectal cancer, as defined by
tumours within 6 cm from the anal verge, has varied
between 80 per cent and 92 per cent over the past
15 years (Figure 8.2). Thus, APE is still a common
operation for low rectal cancer. Since the results
have been suboptimal, it is important to change the
concept of APE to reduce the rate of inadvertent
bowel perforations and tumour-involved margins
and thereby obtain improved oncological outcomes.
The new concept of
abdominoperineal excision
One obvious problem associated with the conven-
tional type of synchronous combined APE is the lack
of standardization. Although the abdominal part of
HEBK001-C08_p124-139.indd 127
PREOPERATIVE PREPARATION  127
APE Hartmann
1999 2001 2003 2005 2007 2009 2011
the operation follows the standard TME principles,
there has been no obvious agreement on the surgi-
cal details of the perineal part of the operation. This
probably explains the significant variability in the
observed rates of tumour-involved margins, bowel
perforations, local recurrence and survival.20 Due
to this variability, and the suboptimal results after
APE, there has been a call for a different concept and
a more standardized approach to APE.21 In recent
years, a new concept of APE has therefore evolved,
which takes into account the specific anatomical
structures of the perineum and the pelvic floor and
which aims to adopt and standardize the procedure
according to the characteristics of the patient and the
tumour. Three basic types of APE can be described
in relation to the perineal approach and the extent of
dissection: the intersphincteric APE, the extralevator
APE and the ischioanal APE. The mobilization of the
rectum and the mesorectum during the pelvic dis-
section in the abdominal part of the operation differs
between the intersphincteric APE and the two other
types. In addition, the indications are different for
the three procedures, as shown in Table 8.1.
PREOPERATIVE PREPARATION
All patients planned for an APE should be well
informed about the extent of the procedure, the
potential complications that may occur postoper-
atively, and the possible late sequel that they may
have to live with. These adverse outcomes after APE
surgery are discussed below.
A crucial part of the preoperative preparation
and information is to have the patient meet a stoma
08/02/13 5:54 PM
 128  Abdominoperineal excision of the rectum
Table 8.1. Indications for APE in rectal cancer
Inter-sphincteric APE
•  Patient unsuitable for bowel reconstruction
•  Preoperative history of incontinence
•  High risk of anastomotic leak
•  Co-morbidity: crucial to prevent leakage + fatal outcome
•  Patient’s preference
Extra-levator APE
•  Tumour extending less than 1 cm from dentate line
(T2 – T4 cancer)
•  Tumour threatening CRM
Ischio-anal APE
•  Locally advanced cancer infiltrating levator muscles,
ischio-anal fat or peri-anal skin
•  Perforated cancer with abscess or fistula in ischio-anal
compartment
nurse, well ahead of the operation. The stoma nurse
has an important role in informing the patient
about the practicalities around stoma care and how
to use bags and other aids. It is also very important
that the placement of the stoma is assessed carefully
to avoid a suboptimal placement, close to a skin-
fold or a scar. The patient needs to be able to see
the stoma, which may be a problem in patients who
are obese if the stoma is placed too low. Thus, the
stoma site should always be marked in advance by
the stoma nurse.
Prophylaxis against deep venous thromboem-
bolism should be administered the evening before
surgery, and antibiotic prophylaxis against post-
operative infection should be given, either orally
in the morning or intravenously within 30 min of
the abdominal incision. Per oral mechanical bowel
preparation is not necessary for APE, but it is rec-
ommended to give an enema to clear the rectum in
the morning before surgery. After administration of
general anaesthesia, a bladder catheter is inserted.
The main reason for this is to identify the urethra
during the perineal phase of an extralevator APE or
ischioanal APE. Our preference is to keep the cath-
eter closed and to insert a suprapubic catheter once
the abdomen is opened. The urethral catheter is
removed directly after surgery and the suprapubic
catheter kept postoperatively. In patients scheduled
for an intersphincteric APE, there is no need for a
urethral catheter, as the perineal dissection is car-
ried out between the internal and external sphinc-
ter, at a safe distance from the urethra.
HEBK001-C08_p124-139.indd 128
The patient is placed in a modified lithotomy posi-
tion, with the buttocks brought down to the edge of
the table and the legs placed in soft stirrups, but the
legs are not elevated during the abdominal phase. A
preoperative briefing is important to allow the sur-
geon to share the plan with the entire operative team
and to confirm the presence of appropriate instru-
ments such as self-retaining retractors, St Mark’s pel-
vic retractors, a variety of staplers and other devices,
including long instruments. Headlights or lighted
retractors may facilitate dissection deep in the pelvis.
The assistance of an experienced second surgeon is
invaluable and strongly recommended.
The surgeon should reassess the rectal cancer by
digital rectal examination and confirm the degree
of involvement of the anal sphincter or other organs
and the level of the distal edge of the tumour. In
female patients, the vagina must be examined to
assess the relation of the tumour to the posterior
vaginal wall. The abdomen and perineum, includ-
ing the vagina in female patients, should be pre-
pared and properly draped.
ABDOMINAL PROCEDURE IN
ABDOMINOPERINEAL EXCISION
With a few exceptions, the approach and the opera-
tive technique for the abdominal part of this pro-
cedure are identical to those used with TME and
anterior resection, as described in Chapter 6.
The abdomen is opened through a midline inci-
sion and the entire abdominal cavity is explored to
detect any metastatic disease or other unexpected
pathology. The small bowel is packed into the upper
abdomen, the patient is placed in a slight Trendelen-
burg position, and a self-retaining retractor is insert-
ed. The sigmoid colon may be mobilized from medi-
al to lateral or vice versa, although it is our preference
to start the mobilization laterally. The sigmoid colon
is retracted to the right and the peritoneal attach-
ments laterally are incised along the avascular plane
(white line of Toldt), distally to the level of the prom-
ontory and as far proximally as needed. It is usually
necessary to mobilize a portion of the descending
colon to allow the later construction of a tension-
free end colostomy, elevated 1 cm above the skin
level. A complete takedown of the splenic flexure, as
is routinely done if a low anastomosis is planned, is
usually unnecessary for an APE. The left ureter and
08/02/13 5:54 PM
 PELVIC DISSECTION IN INTERSPHINCTERIC ABDOMINOPERINEAL EXCISION  129
gonadal vessels are identified and preserved by using
sharp and gentle blunt dissection to separate the ret-
roperitoneal tissues from the left colonic mesentery.
The sympathetic nerve plexus in front of the aorta
is identified, and the dissection continues in front
of these nerves and from left to right, just posterior
to the inferior mesenteric artery (IMA). The perito-
neum on the right side of the colonic mesentery is
then opened and the IMA is followed proximally to
its origin at the aorta.
There is no consensus on where to divide the
IMA. Some surgeons prefer a high ligation at the ori-
gin from the aorta and suggest that this maximizes
the lymph node yield and may improve oncological
outcome. Other surgeons have a preference for a low
ligation just distal to the left ascending colic artery
and argue that this ensures a better blood supply
to the remaining left colon and may prevent nerve
damage at the base of the IMA, resulting in less func-
tional impairment. There is not enough evidence to
state that one approach is better than the other. After
ligation of the IMA and the inferior mesenteric vein
at the same level, the sigmoid mesentery is divided
with diathermy coagulation of small vessels, division
and ligation of the marginal artery, and finally divi-
sion of the colon at the level of the proximal sigmoid
colon, preferably with a linear stapler to prevent any
faecal contamination.
PELVIC DISSECTION
IN INTERSPHINCTERIC
ABDOMINOPERINEAL EXCISION
Pelvic dissection in intersphincteric APE is identi-
cal to that performed for anterior resection, which
is described in detail in Chapter 6. In summary, the
loose connective tissue plane (‘holy plane’) separat-
ing the mesorectal fascia from the parietal pelvic
structures is identified and followed first posteriorly,
then to the left and right, and finally anteriorly while
the peritoneum is gradually divided. Gentle traction
on the specimen and counter-traction with appro-
priate retractors is crucial to achieve a good view of
this plane. The superior hypogastric plexus is iden-
tified at the sacral promontory and the hypogastric
nerves should be identified, protected and preserved
while the dissection gradually proceeds downwards
in the pelvic cavity. Anteriorly the dissection is con-
ducted just posterior to the vesicles and prostate
HEBK001-C08_p124-139.indd 129
in male patients and the vagina in female patients.
The lower anterolateral dissection is the most dif-
ficult part of the abdominal phase of the operation
because the correct plane is often difficult to find
here, and the inferior hypogastric plexus must be
carefully preserved to maintain postoperative sexual
and urinary function. Reducing the angle of the
Trendelenburg position or even shifting the patient
to a reverse Trendelenburg position may facilitate
the exposure for the anterior dissection.
Mobilization of the rectum with an intact mes-
orectum is continued down to the pelvic floor and
the puborectalis muscle. Because the intersphinc-
teric APE is generally not performed when the
tumour is close to the anus, a transverse stapler can
be put across the rectum below the tumour to seal
the bowel and to prevent leakage of mucus or faeces
from the anus.
Perineal Part of Intersphincteric
Abdominoperineal Excision
The patient’s legs are elevated and the perineum is
exposed. The surgeon and assistant now move from
the abdomen to perform the perineal phase of the
intersphincteric APE. The anal canal is washed out
and an incision is made around the anus, just dis-
tal to the intersphincteric groove. A self-retaining
retractor with hooks is recommended to optimize
the view and to facilitate the intersphincteric dis-
section. Once the skin incision is made, the anus is
closed with a running suture. The dissection then
follows the intersphincteric plane between the inter-
nal and external sphincter, around the circumfer-
ence of the anal canal, and all the way up to the pub-
orectal sling and into the pelvic cavity (Figure 8.3A).
The specimen is gently removed through the
perineal incision or, if the mesorectum is large
and bulky, lifted up from the pelvis and removed
from the abdomen via the abdominal incision
(Figure 8.3B).
The perineal incision is closed subcutaneously
with a running or interrupted suture in the pub-
orectalis and external sphincter. It is our preference
to use a running suture in three layers, where the
most superficial suture line is placed subdermal to
leave the skin unsealed in order to allow for dis-
charge of fluid from the wound.
08/02/13 5:54 PM
 130  Abdominoperineal excision of the rectum
Levator ani
Obturator internus
Ischicanal fossa
External sphincter
Internal sphincter
Finalizing the Abdominal Procedure
When the perineum is closed, the patient’s legs are
put down and the abdominal part of the operation
continues with a washout of the pelvic cavity, pref-
erably with sterile water or some other cytotoxic
agent, and haemostatic control.
Omentoplasty
Bowel obstruction due to entrapment of the small
bowel in the pelvic cavity is not infrequent after APE.
Therefore, if the patient has a large omentum, this may
HEBK001-C08_p124-139.indd 130
Figure 8.3a. The pelvic dissection
in an inter-sphincteric APE is carried
along outside the mesorectal
fascia down to the top of the anal
canal (blue line) and the perineal
dissection is carried out between
the internal and external anal
sphincter (red line). The two
dissection planes meet at the level
of the puborectal muscle.
Figure 8.3b. Photograph showing
a fresh specimen after an inter-
sphincteric APE.
be mobilized from the transverse colon and from the
greater curvature of the stomach to prepare an omen-
toplasty, which can help to fill out the empty pelvic
cavity. We prefer to place a drain in the pelvic cavity,
but there is no substantial evidence that this is of any
value. Finally, a thorough control of haemostasis in
the abdomen and pelvic cavity is mandatory before
stoma formation and closure of the abdominal wall.
Stoma Formation
A circular incision is made in the skin at the marked
stoma site, and the dissection is carried through the
subcutaneous fat down to the aponeurosis covering
08/02/13 5:54 PM
 EXTRALEVATOR ABDOMINOPERINEAL EXCISION  131
the rectus abdominis muscle. There is no consensus
on how to incise this aponeurosis; some surgeons
make a longitudinal incision, others prefer a cross-
incision, while some make a round hole and remove
a small disk of the aponeurosis. The fibres of the
rectus abdominis muscle are gently separated and
the posterior sheet and peritoneum is opened.
The divided sigmoid or descending colon is now
picked up and brought out through the stoma site.
At this point it is vital to ensure that the bowel is of
sufficient length and has a good blood supply. The
bowel should not be opened at this point, and not
until the abdominal wall is closed and the wound
properly dressed.
In recent years some authors have advocated plac-
ing a lightweight mesh in a sublay position, deep to
the rectus abdominis muscle, to prevent parastomal
hernia formation, a complication that is frequent in
patients with a colostomy. The use of a preventive
mesh in colostomy formation is described in more
detail below.
Once the bowel has been pulled through the sto-
ma site, the abdominal wall is closed. This may be
done in different ways, but we strongly advocate a
monofilament absorbable or non-resorbable suture,
a short distance between stitches, and a suture length
to wound length ratio of at least 4 to reduce the risk
of wound dehiscence and the later development of
incisional hernia. The skin and wound are cleaned
with saline and the wound is dressed with an appro-
priate bandage.
The exteriorized bowel is now opened, everted
and fixed to the skin with interrupted monofila-
ment sutures. Finally, a stoma bag is placed to cover
the stoma.
EXTRALEVATOR
ABDOMINOPERINEAL EXCISION
The main objective of an extralevator APE is to
diminish the risk of inadvertent bowel perforation
and tumour involvement of the circumferential
resection margins. This is a consequence of excision
of the levator muscles en bloc with the mesorectum
to protect the most distal part of the bowel, thereby
avoiding the ‘waist’ of the specimen, which has been
so common after the conventional type of synchro-
nous combined APE. Since the levator muscles
should not be separated from the mesorectum, the
HEBK001-C08_p124-139.indd 131
pelvic dissection during the abdominal part of an
extralevator APE differs notably from an anterior
resection or an intersphincteric APE (Figure 8.4A).
Pelvic Dissection in Extralevator
Abdominoperineal Excision
The initial abdominal and pelvic dissection is iden-
tical to that described above, but with one very
important difference. In both anterior resection
and intersphincteric APE, the dissection continues
all the way down to the pelvic floor and the pub-
orectalis muscle and subsequently the mesorectum
is lifted off the levator muscles. In extralevator APE
it is crucial not to take the mobilization of the rec-
tum and mesorectum as far down as the pelvic floor.
Instead, the dissection should proceed only down to
the sacrococcygeal junction dorsally, just beyond the
inferior hypogastric plexus anterolaterally, and ante-
riorly dissection should stop just below the seminal
vesicles in male patients or the cervix uteri in female
patients. By terminating the mobilization of the rec-
tum and mesorectum at this level, the mesorectum
is still attached to the levator muscles of the pelvic
floor, which is a crucial feature of extralevator APE.
After completion of the dissection down to this lev-
el, the pelvic cavity is rinsed as described above. The
final steps of the abdominal procedure are carried
out just as for intersphincteric APE, the abdominal
wall is closed and the stoma fashioned.
Perineal Part of Extralevator
Abdominoperineal Excision
The perineal part of extralevator APE differs consid-
erably from the perineal part of intersphincteric APE.
This part of the operation can be performed with
the patient in the supine Lloyd Davies position, or in
the prone jack-knife position. Our preference is the
prone jack-knife position, due to the excellent expo-
sure of the operative field. Other surgeons prefer the
supine position, mainly to avoid the time-consuming
process of turning the patient and subsequent prepa-
ration and dressing of the perineal area. The pros and
cons of the two different positions during the peri-
neal phase of the operation are discussed below.
With the patient in the prone jack-knife posi-
tion, the exposed, washed and sterile operative field
should be well wide of the anus, laterally halfway
08/02/13 5:54 PM
 132  Abdominoperineal excision of the rectum
Levator ani
Obturator internus
Ischieanal fossa
External sphincter
Internal sphincter
along each buttock and dorsally up to the level of
the mid-sacrum. In male patients the scrotum and
penis should be covered and kept out of vision to
expose the whole perineum. In female patients
the vagina should be washed out and kept in the
operative field. In male patients a urethral catheter
must be in place even if a supra pubic catheter has
been inserted during the abdominal phase of the
operation. This is to ensure that any damage to the
urethra during the dissection in the anterior plane,
between the rectum and the prostate, can be detect-
ed and taken care of immediately if it occurs.
The perineal phase starts with closure of the anus
to avoid any spillage of faeces or mucus, which could
contain tumour cells. The aim of anal closure is thus
to reduce infection and reduce the risk of tumour
contamination, which may result in local recurrence.
HEBK001-C08_p124-139.indd 132
Figure 8.4a. The pelvic dissection
in an extra-levator APE is carried
along outside the mesorectal fascia
but stops at the top of the levator
muscle (blue line). The perineal
dissection proceeds just outside
the external sphincter and along
the levator muscle fascia, up to
its origin at the obturator internus
muscle (red line).
Figure 8.4b. Photograph showing
a fresh specimen after an extra-
levator APE. The specimen is more
cylindrical, without a waist, because
the levator muscle is attached to the
mesorectum.
Closing the anus can be done with a double purse-
string suture or with an inverting running suture
after the skin incision has been made around the
anus. The latter technique is ­especially valuable in
very low advanced tumours, which may protrude
through the anus. After closure of the anus, it is rec-
ommended to wipe the operative field once more
with an alcohol solution or another appropriate
antibacterial solution.
In extralevator APE, less skin and ischioanal fat
are excised compared with Miles’ original descrip-
tion of the perineal part of the APE procedure.
Instead, the skin is incised around the anus, with a
margin of only about 3 cm anteriorly and laterally;
posteriorly the incision is carried up to the level of
the lower sacrum, i.e. 2–3 cm cranial to the sacro-
coccygeal junction.
08/02/13 5:54 PM
 EXTRALEVATOR ABDOMINOPERINEAL EXCISION  133
With gentle traction and counter-traction on
the skin edges, the dissection is continued in the
­subcutaneous fat. As the dissection proceeds deeper,
it is important to identify the subcutaneous exten-
sion of the external sphincter. These fibres of striat-
ed muscle should be kept medially, and the dissec-
tion follows a plane between the external sphincter
and the thin fascia covering the ischioanal fat in the
ischioanal compartment (also called the ischiorec-
tal fossa) on both sides. At the top of the external
sphincter and puborectal muscle, the levator ani
muscles are in direct continuity and the dissection
is carried along the surface of the levator muscles all
the way up to their insertion at the pelvic side-wall,
i.e. the obturator internus muscle.
The pudendal nerve, derived from S2–4, runs
together with the pudendal vessels through Alcock’s
canal and converges towards the midline on the
outer anterior surface of the levator muscles. Small
branches of blood vessels and nerves deriving from
the pudendal vessels and nerve cross the space
between the ischioanal compartment and the leva-
tor muscles, and these are divided by diathermy.
Once the surface of the levator muscles is exposed
all around the circumference, haemostasis must be
controlled before entering the pelvic cavity.
In the midline, the levator muscles are attached
to the anterior surface of the coccyx and continue
as the presacral fascia on the anterior lower aspect
of the sacrum. The dissection follows the proxi-
mal portion of the levator muscles on both sides
of the coccyx so that the coccyx is clearly exposed.
An incision is made at the sacrococcygeal junction,
which is easily identified by gentle moving of the
coccyx. Once the cartilaginous connection between
the sacrum and coccyx has been opened, the coc-
cyx is pressed anteriorly to stretch the presacral fas-
cia, which is then divided and an entrance into the
pelvic cavity created. At this stage it is important to
identify the mesorectum in order to not injure the
mesorectal fascia.
The pelvic floor, i.e. the levator muscle, is now
divided from posterior to anterior, first on one side
and then on the other side. As the division of the pel-
vic floor continues anteriorly, it is important to avoid
division of the levator muscles too far laterally and
too close to the ischial tuberosity as this may injure
the main pudendal nerve and vessels in Alcock’s
canal. The division of the pelvic floor continues until
the dorsolateral part of the prostate or vagina can be
HEBK001-C08_p124-139.indd 133
palpated and visualized, or preferably 1–2 cm poste-
rior to this point. The specimen is now still attached
to the anterior aspect of the levator muscles and to
the prostate or posterior wall of the vagina.
The dissection in the anterior plane during the
perineal phase of extralevator APE is the most dif-
ficult, and potentially most dangerous, part of the
procedure because of the close relationship between
the anterior rectal wall and the prostate or posterior
vaginal wall. In addition, the neurovascular bun-
dles derived from the inferior hypogastric plexus
run anterolaterally on each side of the prostate or
vagina and close to the rectum and are easily dam-
aged if they are not recognized at this stage of the
operation. The dissection along the anterior and
lateral aspects of the lower rectum must therefore
be performed meticulously and with great care. If
the dissection is performed close to the rectal wall,
there is a risk of inadvertent perforation or tumour-
involved margin; if the dissection is carried out too
laterally or too anteriorly, there is a risk of damage
to the neurovascular bundles or to the prostate or
vagina. In anteriorly located tumours, it may be
necessary to include the posterior vaginal wall or
a slice of the posterior prostate with the specimen,
and sometimes even to sacrifice the neurovascular
bundle on one side, to be able to achieve a nega-
tive CRM. This extension of the procedure should
ideally be planned in advance, however, so that the
surgeon is prepared for it and the patient is well
informed about the consequences, which may be
impairment of bladder or sexual function.
To facilitate the anterolateral dissection of the
lower part of the rectum, it is recommended that the
specimen is gently brought out of the pelvic cavity
so that the anterior aspect of the bowel can be seen.
It is now easy to look into the pelvic cavity and to
recognize the seminal vesicles and upper part of the
prostate in male patients and the posterior vaginal
wall in female patients. The plane between Denonvil-
lers’ fascia and the prostate or posterior vaginal wall
is now followed carefully while the surgeon attempts
to identify the neurovascular bundles on each side.
Gradually, these planes of dissection are developed
anteriorly and alternately on the right and left sides,
and the remaining part of the levator muscles that
are attached to the lowest part of the rectum are
divided. Finally, the puborectal muscle on each side
and the perineal body just posterior to the transverse
perineal muscle is divided and the specimen can be
08/02/13 5:54 PM
 134  Abdominoperineal excision of the rectum
delivered. The excised specimen is cylindrical, usu-
ally without a waist, due to the fact that the levator
muscle is still attached to the mesorectum, forming
a cuff around the rectal muscle tube (Figure 8.4B).
As soon as the specimen is removed, it is crucial
to control haemostasis at the back of the prostate or
vagina, along the neurovascular bundle on each side
and on the pelvic side-walls. When bleeding is com-
pletely controlled, the pelvic cavity is rinsed with ster-
ile water or another appropriate cytotoxic solution.
If an omentoplasty has been prepared, the omentum
is now gently brought down into the pelvis by gentle
traction. This manoeuvre may be difficult, especially
if a large omentum is to be pulled down into a narrow
pelvis. Therefore, it is recommended that the omen-
tum is attached to the proximal end of the specimen
with a couple of sutures during the abdominal phase
of the operation. This significantly facilitates the
placement of the omentum in the pelvic cavity, since
the omentum slides down into the pelvis when the
rectum is gently pulled out during the perineal phase
of the operation. Care should be taken not to rotate
the omentum by 360 as this will impair its blood
supply and may result in omental necrosis. At this
stage the pelvic drain, placed through the abdomen,
is also brought down into the pelvic cavity.
The next step of the operation is to reconstruct
and close the pelvic floor. As discussed below, there
are several alternative methods available to com-
plete this reconstruction.
ISCHIOANAL ABDOMINOPERINEAL
EXCISION
In some patients, the rectal tumour is locally
advanced and may infiltrate or even perforate
the pelvic floor, i.e. the levator muscle. In other
patients, a perianal abscess may be the present-
ing feature of a perforated low rectal cancer, and
after drainage a fistula may persist between the
low rectum and the perianal skin. In a few very low
tumours, the growth may extend into the perianal
skin (Figure 8.5). In these instances, extralevator
APE may not be sufficient to achieve a safe tumour-
free CRM, and ischioanal APE is usually required to
obtain an oncologically secure margin. In this situ-
ation, the levator muscle must be removed covered
with ischioanal fat, and the ischioanal fat must be
removed to include the perianal fistula, which may
HEBK001-C08_p124-139.indd 134
Figure 8.5. In some very low and advanced tumours the
cancer growth may infiltrate the perianal skin. In these patients
a wide excision of the perianal skin and an ischio-anal APE is
necessary to achieve a potentially curative resection.
contain tumour cells. Therefore, ischioanal APE is a
valid procedure in these special situations.
The abdominal part of ischioanal APE is exactly
equivalent to the abdominal part of extralevator
APE. Thus, the dissection stops just above the levator
muscle and leaves the mesorectum attached to the
pelvic floor (Figure 8.6A). When the abdominal part
of the procedure is completed, with closure of the
abdominal wall and formation of a ­colostomy, the
patient is turned into the prone jack-knife ­position.
Perineal Part of Ischioanal
Abdominoperineal Excision
After proper preparation of the skin of the perineum,
lower sacrum, the medial parts of the buttocks and
the vagina in female patients, a double purse-string
suture is placed to close the anus. The area of the skin
incision in ischioanal APE depends on the extent of
tumour involvement of the skin. Any tumour infiltra-
tion or fistula opening must be included in the excised
skin area with a margin of at least 2–3 cm. As soon
as the incision deepens into the subcutaneous space,
the dissection should be directed laterally towards the
ischial tuberosity and progress on to the fascia of the
internal obturator muscle. Thus, ­contrary to extrale-
vator APE, the dissection does not follow the external
sphincter and levator muscle but instead is carried
along the fascia of the internal obturator muscle. The
dissection is performed along this plane up to where
the levator muscle is inserted into the internal obtu-
08/02/13 5:54 PM
 ISCHIOANAL ABDOMINOPERINEAL EXCISION  135

Figure 8.6a. The pelvic dissection A

in an ischio-anal APE is carried
along outside the mesorectal fascia
but stops at the top of the levator
muscle (blue line). The perineal
dissection is directed towards tuber
os ischii and follows the obturator
Levator ani
internus muscle fascia, in order to
remove the fat in the ischio-anal Obturator internus
compartment en bloc. The size of
the skin incision depends on the Ischio-anal fossa
extent of tumour involvement in the
skin and may be extensive (left side) External sphincter
or similar to the skin incision in an
extra-levator APE (right side). Internal sphincter

Figure 8.6b. Photograph showing

a fresh specimen after an ischio-anal
APE. In very advanced tumours,
infiltrating the perineal skin, a wide
skin excision and a complete
clearance of both ischio-anal
compartments may be necessary
for a potentially curative operation.

rator muscle and hence includes the entire fat com-
partment of the ischioanal space. This dissection can
be performed unilaterally or bilaterally, depending
on the extent of tumour growth. When the dissec-
tion up to this level is completed, the sacrococcygeal
junction is incised and the pelvic cavity is entered
in the same fashion as with extralevator APE. The
subsequent dissection is also similar to that of extra-
levator APE, as the levator muscles are divided along
the fascia of the internal obturator muscle on to the
prostate in male patients or the vagina in female
patients. Once the specimen has been brought out of
the pelvic cavity, the anterior and lateral dissection
along the prostate or vagina is also carried out as in
extralevator APE. As mentioned above, the difference
between extralevator APE and ischioanal APE is that
the fat in the ischioanal space is resected en bloc and
attached to the levator muscle (Figure 8.6B). This
procedure is very similar to what Miles described in
1908 in his original paper in the Lancet.

HEBK001-C08_p124-139.indd 135 08/02/13 5:54 PM

 136  Abdominoperineal excision of the rectum
LAPAROSCOPIC APPROACH TO
ABDOMINOPERINEAL EXCISION
The abdominal procedure in APE may be performed
with minimally invasive techniques, either laparo-
scopic or robot-assisted. This approach is gaining
increasing popularity, and it may well be that mini-
mally invasive methods for the abdominal part of
the operation will become predominant in the near
future. Although some details differ between the
open and minimally invasive approach, the main
principles described above for the abdominal part
of APE should be adopted, irrespective of the sur-
gical method used. The principles and details of
minimally invasive procedures in rectal cancer are
described in Chapter 10.
Prone or supine position
during perineal dissection
In Miles’ original description of the APE procedure,
the perineal part of the operation was performed
in the right lateral and semiprone position after
completion of the abdominal phase and the stoma
creation. Subsequently, synchronous combined APE
gained popularity and became standard for the vast
majority of surgeons. With synchronous combined
APE, the perineal part of the operation is performed
with the patient in the supine Lloyd Davies position,
and the final part of the pelvic dissection from the
abdominal side is often performed simultaneously
with the perineal dissection. In addition, historically
this perineal dissection was often done blunt and
often by the most junior surgeon in the operating
team. As mentioned above, the consequence of this
approach was repeatedly that the excised specimen
had a waist just proximal to the puborectal sling and
often also an inadvertent perforation or an involved
circumferential resection margin.
Due to the increasing awareness of the problems
associated with synchronous combined APE, extra-
levator APE was introduced as a different and more
radical procedure, performed via the posterior
perineal approach in the prone jack-knife position,
which closely mirrors the original Miles opera-
tion.22 The main purpose of this prone jack-knife
position is to optimize the visibility of the operative
field and to have full control of the perineal and pel-
vic floor anatomy. As a result, the correct anatomi-
HEBK001-C08_p124-139.indd 136
cal planes can be followed more easily and the risk
of perforation or involved margins of the specimen
by tumour can be reduced.
In one study, it was shown that the risk of perfo-
ration in extralevator APE was significantly lower
when perineal dissection was carried out in the
prone jack-knife position rather than the lithotomy
or Lloyd Davies position (6.4 per cent v. 20.6 per
cent).23 As perforation of the specimen is a well-
known risk factor for adverse prognosis, it may be
that the prone jack-knife position improves onco-
logical outcomes.
Thus, performing the perineal part of APE with
the patient in the prone jack-knife position may
potentially improve prognosis. In addition, this posi-
tion gives an excellent view, which facilitates teaching
of this part of the operation. With the patient in this
position and with the legs spread apart, the surgeon
stands between the legs and has one assistant on each
side. The operative field is well exposed to all three
surgeons, and trainees can perform a step-by-step
approach to learn how to do the operation, with full
control by the responsible surgeon.
Many surgeons who have adopted extralevator
APE for low rectal cancer also favour the jack-knife
position for the perineal part of the procedure.
Some surgeons still use the lithotomy or Lloyd Dav-
ies position, however, for the perineal part, even
though they perform extralevator APE.24 There has
been some debate about the pros and cons of the
two approaches, and there have also been reports
on excellent oncological outcomes after APE with
the perineal dissection performed with patients in
the supine position.25 It is likely that the position
of the patient is not crucial, provided that skilled
and properly trained surgeons perform a meticu-
lous dissection to create a perfect specimen in the
extralevator plane.26
REMOVAL OF THE COCCYX
With the conventional synchronous combined APE,
the pelvic dissection during the abdominal part of
the operation is carried along the mesorectal fascia
all the way down to the pelvic floor and beyond the
coccyx. With this approach, there is no rationale for
removing the coccyx while performing the perineal
part of the operation, because the mesorectum has
already been detached from the levator muscle of
08/02/13 5:54 PM

the pelvic floor. Therefore, the division of the leva-
tor muscle during conventional APE is often insti-
gated between the tip of the coccyx and puborectal
sling and continued forwards bilaterally on to the
prostate or the vagina. With this approach, a lim-
ited amount of the pelvic floor muscle is removed
en bloc with the rectum and, as mentioned earlier,
the specimen frequently has a waist just above the
puborectal sling.
During extralevator APE and ischioanal APE,
the coccyx is often removed en bloc with the rec-
tum. There are two main reasons for doing this:
first, the levator muscle is attached to the anterior
surface of the coccyx and continues cranially as
the presacral fascia. If the levator muscle is to be
completely removed and fixed to the mesorectum,
as in extralevator APE, then the coccyx needs to be
removed. Cutting the levator muscle below the tip
of the coccyx will inevitably leave a part of the leva-
tor muscle behind. Second, it is sometimes difficult
to bring out the specimen from the pelvic cavity
through a narrow opening in the pelvic floor. Espe-
cially in male patients with a narrow pelvis and a
large mesorectum, it can be hard to bring out the
specimen before starting the challenging dissection
of the anterior part of the rectum and mesorectum
off the prostate or the vagina. By dividing between
the sacrum and the coccyx and excising the coccyx
en bloc, the surgeon creates a wider opening of the
pelvic floor, which facilitates delivery of the speci-
men and the anterior dissection. Some authors have
advocated an even more extensive resection includ-
ing the last sacral vertebra to achieve better access
and control of the perineal part of the operation.27
With the patient in the supine, lithotomy or
Lloyd Davies position, removal of the coccyx is dif-
ficult due to limited access to the natal cleft. There-
fore, surgeons who are proponents of removal of
the coccyx usually also perform the perineal part of
extralevator APE in the prone jack-knife position.
Using a mesh to prevent
parastomal hernia
One major problem after APE with formation of a
permanent stoma is the subsequent development
of a parastomal hernia in many patients, which
by definition is an incisional hernia related to the
presence of a stoma in the abdominal wall. This is
HEBK001-C08_p124-139.indd 137
PERINEAL RECONSTRUCTION  137
a common clinical problem, reported to occur in
30–80 per cent of patients with a colostomy. The
wide variation in incidence is probably related to
the definition of a parastomal hernia, the method
used to diagnose the condition and the length of
follow-up. Although many parastomal hernias are
only cosmetically disturbing or associated with
mild symptoms, about 30–40 per cent of patients
with parastomal hernias may require surgical repair
of the hernia due to pain, obstruction, bleeding,
increasing protrusion, poorly fitting stoma bag, fae-
cal leakage or incarceration. Several different surgi-
cal methods are used to treat parastomal hernias,
including relocation, primary closure of the fascia
and mesh repair, but high complication and recur-
rence rates have been reported. The use of a pros-
thetic mesh to repair a parastomal hernia and to
reconstruct the abdominal wall has gained increas-
ing popularity and improved the rate of successful
revisions, but these methods are not without prob-
lems. Erosion of the bowel (with subsequent infec-
tion and fistula formation) and recurrent hernia
development have been reported. The high risk of
parastomal hernia and the suboptimal results after
repair have led to attempts to prevent its occur-
rence. Several studies have shown that the use of a
polypropylene mesh at the time of stoma formation
is safe and may prevent the occurrence of a paras-
tomal hernia. A review of three randomized con-
trolled trials and three prospective observational
series reported parastomal hernia rates of 55 per
cent in patients who did not have a mesh and 7 per
cent in patients in whom a mesh was used. Post-
operative morbidity rates were similar, irrespective
of whether a mesh was used.28 Although the place-
ment of a mesh, preferably by a sublay technique,
seems promising, there are no data on long-term
results in terms of hernia recurrence or possible late
complications. Despite this, we recommend the use
of a 10 3 10 cm lightweight synthetic mesh around
the bowel behind the rectus muscle and anterior to
the rectus sheet.
PERINEAL RECONSTRUCTION
When the first major paper on APE was published
by Miles in 1908, he described the closure of the
perineal wound: ‘Finally, the skin margins are
brought together with sutures and a large drainage-
08/02/13 5:54 PM
 138  Abdominoperineal excision of the rectum
tube is inserted in the anterior and the posterior
extremities of the median incision.’ Miles later aban-
doned this technique due to the high risk of perineal
wound infections and the ensuing mortality, and
instead the defect was left open and allowed to heal
by secondary intention. The practice of leaving the
perineal wound open was applied for many decades
but is now used by very few surgeons. Although this
method avoids some of the infectious complica-
tions associated with primary closure, the morbid-
ity associated with a large, slowly healing wound is
significant. Therefore, primary closure of the peri-
neal wound has been the most common method
of ­perineal reconstruction after synchronous com-
bined APE. Although the clinical course after prima-
ry closure is often uneventful, complications due to
the perineal wound are still one of the major prob-
lems associated with the conventional type of APE,
especially in patients who have received preoperative
radiotherapy. Wound problems have been reported
in up to 50 per cent of patients receiving preopera-
tive radiotherapy after APE with primary wound
closure.29 Wound infection and delayed healing are
the most common complications. These problems
may become even more frequent in patients who
have received a combination of preoperative radio-
therapy and extralevator APE, with a more extensive
excision of the pelvic floor.
A variety of surgical alternatives to primary clo-
sure have been used to reconstruct the pelvic floor
and to reduce the wound healing problems after
APE. These procedures include omental pedicle
flaps (omentoplasty) and different local rotational
musculocutaneous flaps. Data from controlled
studies support the use of musculocutaneous flaps
for single-stage reconstruction after APE, especial-
ly in the presence of chemoradiotherapy. Several
reports using the rectus abdominus, gluteus max-
imus or gracilis musculocutaneous flaps have been
published.30,31
Rectus abdominus flaps have been most com-
monly used. The reported overall complication
rates vary from 10 per cent to 50 per cent, while
healing rates during follow-up vary from 95 per
cent to 100 per cent.32,33 Most studies are small,
with fewer than 50 reported patients; the small
number of patients, the varying definition of
wound complications and the varying follow-up
times probably explain the difference in complica-
tion rates.
HEBK001-C08_p124-139.indd 138
Some experience with biological mesh reconstruc-
tion of the pelvic floor has also been reported. This
option seems feasible with a reasonable complication
rate.34 The number of reports is limited, however, and
long-term results from biological mesh reconstruc-
tion of the pelvic floor are still lacking. In fact, there
is no standard solution for pelvic floor reconstruc-
tion after APE, and the method used must be tailored
according to the patient and the extent of excision.
Thus, primary closure is generally appropriate after
intersphincteric APE, while some kind of mesh or
flap reconstruction is often used after extralevator
APE. After ischioanal APE, a flap reconstruction is
almost always necessary, especially if the excision of
skin has been extensive. It is recommended to assess
each patient carefully before surgery to determine
the suitable type of pelvic floor reconstruction and
to establish collaboration with a plastic surgeon for
reconstruction after wider excisions.
References
  1. Miles WE. A method of performing abdomino-perineal
excision for carcinoma of the rectum and of the
terminal portion of the pelvic colon. Lancet 1908; 2:
1812–13.
  2. Collins DC. End-results of the Miles’ combined
abdominoperineal resection versus the segmental
anterior resection: a 25-year postoperative follow-up in
301 patients. Am J Proctol 1963; 14: 258–61.
  3. Fick TE, Baeten CG, von Meyenfeldt MF, Obertop H.
Recurrence and survival after abdominoperineal and
low anterior resection for rectal cancer without adjunc-
tive therapy. Eur J Surg Oncol 1960; 16: 105–8.
  4. Groves RA, Harrison RC. Carcinoma of the rectum
and lower sigmoid colon: abdominoperineal or anterior
resection? Can J Surg 1962; 5: 393–403.
  5. Slanetz CA, Herter FP, Grinnell RS. Anterior resection
versus abdominoperineal resection for cancer of the
rectum and rectosigmoid: an analysis of 524 cases.
Am J Surg 1972; 123: 110–17.
  6. Vandertoll DJ, Beahrs OH. Carcinoma of the rectum
and low sigmoid: evaluation of anterior resection in
1766 favourable lesions. Arch Surg 1965; 90: 793–8.
  7. Schmitz RL, Nelson PA, Martin GB, Boghossian HM.
Synchronous (two-team) abdominoperineal resection
of the rectum. AMA Arch Surg 1958; 77: 492–7.
  8. Påhlman L, Glimelius B. Local recurrences after surgi-
cal treatment for rectal carcinoma. Acta Chir Scand
1984; 150: 331–5.
  9. Heald RJ, Husband EM, Ryall RD. The mesorectum in
rectal cancer surgery – the clue to pelvic recurrence.
Br J Surg 1982; 69: 613–16.
08/02/13 5:54 PM

10. Macfarlane JK, Ryall RD, Heald RJ. Mesorectal exci-
sion for rectal cancer. Lancet 1993; 341: 457–60.
11. Kapiteijn E, Marijnen CA, Nagtegaal ID, et al. Preop-
erative radiotherapy combined with total mesorectal
excision for resectable rectal cancer. N Engl J Med
2001; 345: 638–46.
12. Martling AL, Holm T, Rutqvist LE, Moran BJ, Heald RJ,
Cedemark B. Effect of a surgical training programme
on outcome of rectal cancer in the County of Stock-
holm: Stockholm Colorectal Cancer Study Group,
Basingstoke Bowel Cancer Research Project. Lancet
2000; 356: 93–6.
13. Wibe A, Syse A, Andersen E, Tretli S, Myrvold HE,
Soreide O. Oncological outcomes after total mesorec-
tal excision for cure for cancer of the lower rectum:
anterior vs. abdominoperineal resection. Dis Colon
Rectum 2004; 47: 48–58.
14. Marr R, Birbeck K, Garvican J, et al. The modern
abdominoperineal excision: the next challenge after
total mesorectal excision. Ann Surg 2005; 242: 74–82.
15. Den Dulk M, Putter H, Collette L, et al. The abdomi-
noperineal resection itself is associated with an adverse
outcome: the European experience based on a pooled
analysis of five European randomised clinical trials on
rectal cancer. Eur J Cancer 2009; 45: 1175–83.
16. Nagtegaal ID, van de Velde CJ, Marijnen CA, van
Krieken JH, Quirke P. Low rectal cancer: a call for a
change of approach in abdominoperineal resection.
J Clin Oncol 2005; 23: 9257–64.
17. Eriksen MT, Wibe A, Syse A, Haffner J, Wiig JN.
Inadvertent perforation during rectal cancer resection
in Norway. Br J Surg 2004; 91: 210–6.
18. Pollack J, Holm T, Cedermark B, Holmstrom B,
Mellgren A. Long-term effect of preoperative radia-
tion therapy on anorectal function. Dis Colon Rectum
2006; 49: 345–52.
19. Morris E, Quirke P, Thomas JD, Fairley L, Cot-
tier B, Forman D. Unacceptable variation in
­abdominoperineal excision rates for rectal cancer: time
to intervene? Gut 2008; 57: 1690–7.
20. Birbeck KF, Macklin CP, Tiffin NJ, et al. Rates of
circumferential resection margin involvement vary
between surgeons and predict outcomes in rectal
cancer surgery. Ann Surg 2002; 235: 449–57.
21. Radcliffe A. Can the results of anorectal (abdomi-
noperineal) resection be improved: are circumferential
resection margins too often positive? Colorectal Dis
2006; 8: 160–7.
HEBK001-C08_p124-139.indd 139
References   139
22. Holm T, Ljung A, Haggmark T, Jurell G, Lagergren J.
Extended abdominoperineal resection with gluteus
maximus flap reconstruction of the pelvic floor for
rectal cancer. Br J Surg 2007; 94: 232–8.
23. West NP, Anderin C, Smith KJ, Holm T, Quirke P. Mul-
ticentre experience with extralevator abdominoperineal
excision for low rectal cancer. Br J Surg 2010; 97:
588–99.
24. Martijnse IS, Dudink RL, West NP, et al. Focus on
extralevator perineal dissection in supine position for
low rectal cancer has led to better quality of surgery
and oncologic outcome. Ann Surg Oncol 2012; 19,
786–93.
25. De Campos-Lobato LF, Stocchi L, Dietz DW, Lavery
IC, Fazio VW, Kalady MF. Prone or lithotomy position-
ing during an abdominoperineal resection for rectal
cancer results in comparable oncologic outcomes. Dis
Colon Rectum 2011; 54: 939–46.
26. Bebenek M. Abdominosacral resection is not related
to the risk of neurological complications in patients
with low-rectal cancer. Colorectal Dis 2009; 11: 373–6.
27. Janes A, Cengiz Y, Israelsson LA. Preventing paras-
tomal hernia with a prosthetic mesh: a 5-year follow-
up of a randomized study. World J Surg 2009; 33:
118–21, 122–3.
28. Bullard KM, Trudel JL, Baxter NN, Rothenberger DA.
Primary perineal wound closure after preoperative
radiotherapy and abdominoperineal resection has a
high incidence of wound failure. Dis Colon Rectum
2005; 48: 438–43.
29. Khoo AK, Skibber JM, Nabawi AS, et al. Indications for
immediate tissue transfer for soft tissue reconstruction
in visceral pelvic surgery. Surgery 2001; 130: 463–9.
30. Nisar PJ, Scott HJ. Myocutaneous flap reconstruction
of the pelvis after abdominoperineal excision. Colorec-
tal Dis 2009; 11: 806–16.
31. Mcallister E, Wells K, Chaet M, Norman J, Cruse W.
Perineal reconstruction after surgical extirpation of
pelvic malignancies using the transpelvic transverse
rectus abdominal myocutaneous flap. Ann Surg Oncol
1994; 1: 164–8.
32. Tobin GR, Day TG. Vaginal and pelvic reconstruction
with distally based rectus abdominis myocutaneous
flaps. Plast Reconstr Surg 1988; 81: 62–73.
33. Christensen HK, Nerstrom P, Tei T, Laurberg S.
Perineal repair after extralevator abdominoperineal
excision for low rectal cancer. Dis Colon Rectum 2011;
54: 711–7.
08/02/13 5:54 PM

Laparoscopic surgery
Katharine E. Bevan and Tom D. Cecil
Introduction
Since the 1940s surgeons have used a laparoscope
to inspect the peritoneal cavity. Advances in equip-
ment technology coupled with pioneering ap-
proaches have moved the role of the laparoscope
from a diagnostic to an increasingly therapeutic
tool in managing abdominal pathology. The first
appendicectomy was performed laparoscopically in
the 1980s, closely followed by laparoscopic chole-
cystectomy in 1985. Laparoscopic colonic resec-
tion, particularly for cancer, has been slower in
development and uptake, however. This is unsur-
prising, considering the technical challenges in-
volved, including the necessity to operate in all four
quadrants of the abdomen and the complexity of
the arterial and venous anatomy of the colon. The
need to resect and remove a sometimes substantial
specimen, and subsequently perform a difficult in-
testinal anastomosis, are further challenges. When
considering mid- to lower rectal cancers, there are
additional anatomical and technical difficulties.
These include bulky tumours in a narrow pelvis, re-
traction and visualization (especially with the distal
dissection), preservation of autonomic nerves, ac-
curate circumferential resection (without jeopard-
izing the mesorectal envelope) and technological
challenges (due to current limited angulation of
laparoscopic staplers).
Early anxiety regarding port site metastasis1
combined with a lack of randomized controlled
HEBK001-C09_p140-153.indd 140
9
trials and concerns regarding long-term oncologi-
cal outcomes culminated in a logical reluctance
to embrace laparoscopic colorectal cancer surgery.
There are now a number of randomized control-
led trials comparing laparoscopic and open colon
cancer surgery. The short-term benefits for laparo-
scopic colonic resection have been summarized in a
Cochrane review, with the main disadvantage being
that the surgery is more time-consuming.2 A subse-
quent Cochrane review reported that laparoscopic
surgery was feasible for upper rectal cancers, but
the overall conclusion was that more randomized
controlled trials were required to assess long-term
outcomes.3 A further Cochrane review principally
looking at the safety and efficacy of laparoscopic
versus open total mesorectal excision (TME) for
rectal cancer concluded that ‘the limited evidence
suggests that laparoscopic TME has clinically rel-
evant short-term advantages in selected patients
with rectal cancer’.4 Controversy continues regard-
ing the role of the laparoscope in rectal cancer as
initial reports were from enthusiasts with small
series, with little emphasis on the selection of ap-
propriate patients or the challenges to be overcome
before widespread adoption of safe laparoscopic
rectal cancer surgery.5
The Conventional versus Laparoscopic-Assisted
Surgery in Colorectal Cancer (CLASICC) trial was
the first randomized controlled trial to include pa-
tients with rectal cancers. Outcomes were evalu-
ated separately from colon cancer outcomes. The
08/02/13 5:50 PM
 MODERN MANAGEMENT OF RECTAL CANCER AND THE ROLE OF THE LAPAROSCOPE  141
CLASICC trial highlighted concerns with regard
to an increased circumferential resection margin
(CRM) positivity and suggested that the routine
use of the laparoscope for rectal cancer was not yet
justified.6
In August 2006, the National Institute for Health
and Clinical Excellence (NICE) issued revised
guidelines recommending that laparoscopic sur-
gery (including laparoscopically assisted surgery)
should be offered as an alternative to open surgery
if both techniques are suitable and the appropriate
surgical skills are available.7
This chapter focuses on some issues unique to
laparoscopic rectal cancer surgery. We review the
evidence from randomized controlled trials and
summarize our approach to laparoscopic rectal
resection. The particular problems needed to be
addressed in rectal cancer are explored to give a
balanced and safe approach to the use of the laparo-
scope in rectal cancer and in particular TME.
MODERN MANAGEMENT OF
RECTAL CANCER AND THE ROLE
OF THE LAPAROSCOPE
The modern management of rectal cancer involves
accurate preoperative staging, appropriate neoad-
juvant therapy in selected cases (either preoperative
radiotherapy or chemoradiotherapy), optimal sur-
gical excision and detailed pathological assessment
of the excised specimen.5 All these aspects interact
with the role of the laparoscope in the management
of rectal cancer.
In the absence of longer-term outcome data from
larger clinic trials, a surrogate marker is required to
assess operative success. Macroscopic and micro-
scopic assessment of the specimen, being a prog-
nostic marker for local recurrence as reported in the
Medical Research Council (MRC) CR07 trial, may
be the best method for comparing early oncological
results from both open and laparoscopic surgery.8
Staging and Diagnostic Laparoscopy
Despite advances in non-invasive imaging, laparos-
copy continues to have an important role in some
aspects of staging rectal cancer. Cross-sectional im-
aging is highly sensitive and specific for detection
HEBK001-C09_p140-153.indd 141
of visceral metastases9 and useful for lymph node
assessment.10 Peritoneal carcinomatosis, especially
if localized and low volume,11 and to a lesser extent
local tumour extension, continue to be a challenge to
diagnose, however, despite major advances in imag-
ing. Thus, there continues to be a role for a more sen-
sitive modality such as laparoscopy, and in colorectal
surgery this is particularly so for detection of early,
potentially treatable localized carcinomatosis.12
A pivotal role for staging laparoscopy in colorectal
cancer surgery is undoubtedly a useful initial inves-
tigation when a laparoscopic resection is being con-
templated or planned. The ultimate decision as to
whether laparoscopic resection is safe and feasible,
or whether open surgery is required, is best made at
this point, and experienced surgeons can rapidly de-
cide on the appropriate modality of surgery in most
cases.13
Laparoscopic Stoma Formation
Patients with rectal cancer may, in some circumstanc-
es, require a defunctioning stoma, either as palliative
treatment or before neoadjuvant therapy for very
symptomatic locally advanced tumours. A stoma may
be necessary for obstruction, uncontrollable diar-
rhoea, tenesmus or bleeding and often before chemo-
radiation, as either down-staging or definitive care.
There is considerable variability in the frequency of
defunctioning stoma formation before neoadjuvant
therapy,14 but it undoubtedly has a role and may be
needed before or during neoadjuvant therapy.15
The laparoscope can be used to perform a defunc-
tioning ileostomy or colostomy alone, or as part of
a laparoscopic colorectal resection, or to reduce the
septic complications secondary to anastomotic leak.
In addition, the laparoscopic approach should en-
able correct identification of the proximal and distal
limbs and thus avoid ‘bringing out the wrong limb’,
as surgeons of an older generation have experienced
when fashioning a defunctioning trephine stoma.
Some reports suggest shorter time to passage of
flatus and faeces, earlier resumption of a liquid and
solid diet, decreased morphine requirements, a re-
duction in 30-day morbidity, and earlier discharge
in patients having a stoma formed ­laparoscopically.16
As a consequence, patients in whom defunctioning
alone is required, without resection or anastomo-
sis, are likely to achieve maximal benefit from a
08/02/13 5:50 PM
 142  Laparoscopic surgery
laparoscopic approach due to expedited recovery
and therefore minimal interruption to treatment,
in comparison with open surgery. There have been
reports, however, of obstructive complications after
any proximal defunctioning stoma.
A laparoscopic colostomy is also a very useful
training operation as part of the learning curve for
more complex surgery involving mobilization of
the colon.
Abdominoperineal Excision
of the Rectum
Abdominoperineal excision (APE) was the first re-
sectional laparoscopic colorectal procedure to be
performed for malignancy. As the oncological part
of the operation is carried out by an open surgi-
cal technique from the perineum, it could be con-
fidently attempted without the concern for a major
compromise in the oncological outcome. Patients
with low rectal cancer undergoing APE, particu-
larly with the recent developments in extralevator
APE, have perhaps most to gain by a laparoscopic
approach.17 In extralevator APE, the main onco-
logical part of the procedure is performed via the
perineum, there is no bowel anastomosis, and the
specimen can be removed through the perineum,
such that no abdominal incision is required.17
The upper part of the TME plane is developed
and completed laparoscopically, but without the
need to continue the dissection very far distally.
Subsequently, the perineal plane is developed, usu-
ally after completing the colostomy, closing the
abdomen and turning the patient into the prone
jack-knife position. The dissection proceeds until
the perineal operation meets the extent of the ab-
dominal operation. Additionally, the tumour re-
quiring an APE is generally lower in the rectum,
well below the peritoneal reflection, compared with
cases where reconstruction by an anterior resection
is being performed, and is therefore less likely to
obscure the laparoscopic view or be subject to tu-
mour rupture by traction or retraction.
With the success of laparoscopic APE, enthusi-
asts deemed it as a natural progression to extend the
abdominal surgery deeper into the pelvis in suitable
patients to mobilize the rectum and subsequently
proceed to reconstruction to achieve laparoscopic
anterior resection.18,19
HEBK001-C09_p140-153.indd 142
Evidence for the
laparoscopic approach
to rectal cancer
Short-Term Outcomes
Although there are some conflicting findings, many
of the short-term benefits of laparoscopic colonic
resection have also been reported for laparoscopic
rectal resection.4 These include the earlier return
of bowel function and subsequently resumption of
diet,6,20–23 shorter length of stay,6,20,23 quicker return
to household activities,20 reduced pain and analge-
sia use,20,21 and decreased blood loss,21–23 sometimes
equating to a reduction in the requirement for
blood transfusion (Table 9.1).23
These findings are unsurprising and are consist-
ent with the evidence of a lesser inflammatory re-
sponse and decreased immunological disturbance
in laparoscopic colorectal surgery; some of these
beneficial effects may be due to less small bowel
manipulation.24 On the negative side, the duration
of the laparoscopic operation is longer6,20–23 and the
cost of surgery greater.2,20,23
Lymph Node Harvest
Lymph node harvest has often been considered a short-
term marker for oncological equivalence of open and
laparoscopic resection specimens. A small randomized
controlled trial included 73 patients (39 open surgery,
34 laparoscopic TME) and reported equivalent lymph
node harvest in both groups.25 Subsequently other
studies have reported similar findings.6,20–23
RESECTION QUALITY AND
CIRCUMFERENTIAL
RESECTION MARGIN
It is now widely accepted that TME, as described by
Heald in 1988, is the treatment of choice in ­resectable
rectal cancer.26 Provided a clear CRM can be achieved,
TME results in an improvement in cancer-specific
survival. The effect of the quality of the resected speci-
men is also emerging as a prognostic indicator for lo-
cal recurrence after rectal cancer.
One group showed that both the prospec-
tive histopathological assessment of the plane of
08/02/13 5:50 PM
 RESECTION QUALITY AND CIRCUMFERENTIAL RESECTION MARGIN   143

Table 9.1 Short- and longer-term outcome results reported in the five largest randomized controlled trials comparing
laparoscopic and open surgery for rectal cancer.
Study Kang et al.21 Lujan et al.22 Braga et al.23 Jayne et al.29 Leung et al.20
Open surgery (n) 170 103 85 253 200
Laparoscopic 170 101 83 128 203
surgery (n)
Blood loss Greater in open Greater in open Greater in open NS NS
group, significant group, P 5 0.001 group, P 5 0.0002
Operative time .48 min in .21 min in .53 min in Increased in .45.7 min in
laparoscopy laparoscopy laparoscopy laparoscopy laparoscopy
group, P , 0.0001 group, P 5 0.020 group, P 5 0.0001 group group, P , 0.001
Conversion rate (%) 1.2 7.9 7.2 34 (rectal) 23.2
Analgesic Reduced in NR NR NR Reduced in
requirements laparoscopy laparoscopy
group, P , 0.0001 group, P , 0.001
Return to bowel Reduced time in NR NR NS NS
function laparoscopy
group, P , 0.0001
Return to diet Reduced time in ,1 day in Reduced time in NS Reduced time in
laparoscopy laparoscopy laparoscopy laparoscopy
group, P , 0.0001 group, NS group, P , 0.0001 group, P , 0.001
Length of stay ,1 day in ,1 day in ,3.6 days in ,2 days in Reduced in
laparoscopy laparoscopy laparoscopy laparoscopy rectal laparoscopy
group, NS group, NS group, P 5 0.004 group group, P , 0.001
Lymph node yield NS NS NS NS NS
CRM positivity (%) NS NS NS 12 (laparoscopy) v. NR
6 (open)
30-day morbidity NS NS NS NS NS
Mortality NS NS NS NS NS
Local recurrence at NR 5.3 (open) v. 4.8 NS at 3 years 10.1, NS 6.6 (laparoscopy)
5 years (%) (laparoscopy), NS v. 4.1 (open), NS
Disease-free survival NR 81 (open) v. 84 NS 52.1 (open) v. 53.2 NS
at 5 years (%) (laparoscopy), NS (laparoscopy), NS
Overall survival at NR 75 (open) v. 72 NS 52.9 (open) v. 60.3 NS
5 years (%) (laparoscopy), NS (laparoscopy), NS
Mean follow-up NR 34 (open) v. 32 53.6 56.3 52.7
(months) (laparoscopy)

CRM, circumferential resection margin; NR, not reported; NS, not statistically significant.

surgery and the CRM margin were independent
prognostic markers for local recurrence. Clear dif-
ferences were noted with suboptimal surgery, with
a statistically significant increase in the local re-
currence rate at 3 years. Circumferential resection
margin positivity is still one of the most important
predictors of increased risk of local recurrence and
decreased 3-year survival, regardless of the plane
of dissection.27 It would therefore seem appropri-
ate to use these two standards (plane of surgery
achieved and CRM) as a means of quality control
when comparing laparoscopic and open rectal
cancer surgery.
The evidence base for equivalent clinical out-
comes in rectal cancer treated laparoscopically is
limited but emerging.

HEBK001-C09_p140-153.indd 143 08/02/13 5:50 PM

 144  Laparoscopic surgery

The CLASICC study initially demonstrated con-
cerns with regard to CRM. The study reported more
positive CRMs in the laparoscopic group compared
with the open anterior resection group (12 per cent v.
6 per cent). Although the results were not significantly
different, they were concerning enough to recommend
caution when treating rectal cancer ­laparoscopically.6
These concerns have been somewhat allayed by the 3-
and 5-year follow-up data, which have shown that the
trend towards positive CRM did not translate into an
increase in local recurrence rates.28,29
Five randomized controlled trials, all with at least
80 patients in each arm, have reported longer-term
follow-up data. Three of these trials reported on
rectal cancer outcomes alone.21–23 One trial included
both colonic and rectal cancer and reported on the
rectal subset separately.6 The final trial recruited both
high rectal and sigmoid tumours, but the heteroge-
neity makes interpretation difficult, particularly as
the tumours were not analysed independently.20
None of these trials demonstrated a statistically sig-
nificant difference in CRM positivity (Table 9.2).
Kang’s group looked at macroscopic quality of
the TME dissection and showed no difference be-
tween open and laparoscopic surgery. Three of
the randomized controlled trials have published
long-term survival figures.6,22,23 These studies have
shown no statistical difference in local recurrence,
­disease-free survival or overall survival between
surgical approaches (see Table 9.1).
Some groups have compared the quality of the
mesorectal dissection specimen and reported no
statistical difference between open and laparoscopic
resections.30,31 A comparison of the macroscopic
quality of specimens after laparoscopic32 and open33
TME showed that there was a more complete TME
with intact visceral pelvic fascia in the laparoscopic
group. The investigators concluded that the im-
proved visualization at laparoscopy may result in
improved macroscopic specimens.34
Although the rates of local recurrence vary wide-
ly in the published literature, no significant differ-
ences between laparoscopic and open surgery were
reported in the 2006 Cochrane review4 or in sev-
eral randomized controlled trials.20,22,23 It remains to
be seen whether long-term follow-up consistently
gives results equivalent to those reported for open
TME of less than 5 per cent in curative cases.35
Anastomotic leak and
its influence on local
recurrence
An anastomotic leak after restorative resection of
rectal cancer continues to be a major issue whether
laparoscopic or open surgery is performed. There
have been reports that anastomotic leak may sig-
nificantly increase the local recurrence rates,36 with
poorer overall and cancer-specific survival.37 There-
fore, it is imperative that we have at least equal or
preferably lower anastomotic leak rates when per-
forming laparoscopic surgery for rectal cancer.
None of the randomized controlled trials showed a
statistically significant difference between the open
and laparoscopic groups when comparing leak rates

Table 9.2 Comparison of leak rate within randomized controlled trials comparing laparoscopic and open surgery for
rectal cancer.
Trial Kang et al.21 Lujan et al.22 Braga et al.23 Jayne et al.29 Leung et al.20
Open (n) 170 103 85 132 200
Laparoscopic (n) 170 101 83 160 202
Inclusions ,9 cm from anal Mid- and low rectal ,15 cm from anal .5 cm from anal Rectosigmoid
verge cancers: mean verge verge (67%
6.2 cm (open) v. open v. 79%
5.5 cm (laparoscopy) laparoscopy)
from anal verge
Stoma formation (%) 88.4 (open) v. 91 59 (open) v. 62 24.7 (open) v. 26.5 NR NR
(laparoscopy) (laparoscopy) (laparoscopy)
Leak rate (%) 0 (open) v. 1.2 12 (open) v. 6 7 (open) v. 6 7 (open) v. 8 2 (open) v. 0.5
(laparoscopy) (laparoscopy) (laparoscopy) (laparoscopy) (laparoscopy)

NR, not reported.

HEBK001-C09_p140-153.indd 144 08/02/13 5:50 PM

 OUR APPROACH TO LAPAROSCOPIC ANTERIOR RESECTION  145
(see Table 9.2).6,20–23 Liberal use of defunctioning, ei-
ther in all patients having TME or at a minimum all
patients at increased risk of anastomotic leak (e.g.
male patients, patients with a high body mass in-
dex, patients who have had neoadjuvant treatment,
patients with a low or complex anastomosis), may
significantly reduce the clinical consequences of a
leak. There may be a case for routine defunction-
ing of all anastomoses after any mid- or low rec-
tal cancer resection, as in the Comparison of Open
versus Laparoscopic Surgery for Mid and Low Rec-
tal Cancer after Neoadjuvant Chemoradiotherapy
(COREAN) study.21 It has been noted, however, that
the addition of a defunctioning stoma significantly
increases length of stay after laparoscopic resection,
thereby partly negating this potential benefit of the
laparoscopic approach.21
Length of stay
Reduction in length of stay is often quoted as being
a particular benefit of laparoscopic surgery. Inter-
estingly, two of the five randomized controlled tri-
als did not demonstrate any statistically significant
reduction in length of stay (see Table 9.1).21,22 Braga
and colleagues did report a reduction in length of
stay with laparoscopic surgery, but this study in-
cluded high rectal cancers and had a subsequently
low stoma rate.23 Leung and colleagues also demon-
strated a reduction in length of stay, but their study
included mainly rectosigmoid ­tumours.20
The studies of Kang and colleagues21 and Lujan
and colleagues22 showed no significant reduction in
length of stay. Of note, all patients in the COREAN
trial and over 70 per cent of patients in the Spanish
trial were operated on after neoadjuvant chemora-
diotherapy, and consequently the rates of defunc-
tioning ileostomy were very high (91 per cent and
62 per cent, respectively), which has previously
been shown to increase length of stay.37
Morbidity and mortality
The currently reported randomized controlled trials
have not shown a significant difference with regard
to perioperative mortality.20–23,28 Some studies have
shown lower morbidity in laparoscopic patients,38,39
but this is a minority and many studies have shown
HEBK001-C09_p140-153.indd 145
equivalence.6,20–23 Taken in conjunction with studies on
colonic resection,2,40 the available data suggest possible
benefits in favour of laparoscopic surgery in frailer and
older patients due to fewer complications in the lapar-
oscopic group, especially in people aged over 70 years.40
OUR APPROACH TO
LAPAROSCOPIC ANTERIOR
RESECTION
Preoperative Assessment
The preoperative investigations that we carry out for
laparoscopic anterior resection for rectal cancer are al-
most identical to those for open surgery. Staging com-
puted tomography (CT) of the chest and abdomen
and magnetic resonance imaging (MRI) of the pelvis
are essential. Endoscopic assessment of the entire co-
lon (unless an obstructing tumour limits progress)
allows biopsy confirmation of carcinoma and allows
assessment for synchronous pathology. Unlike open
surgery, tattooing of the location of the tumour is es-
sential. For colon cancers above the peritoneal reflec-
tion, we recommend marking 5 cm distal to the tu-
mour, and usually in three separate locations around
the circumference of the bowel at this level. For rectal
cancer, however, this is unhelpful, as the tumour is be-
low the peritoneal reflection and the tattoo can stain
the mesorectal and fascial planes, making dissection
more difficult. For rectal cancer, we rely on MRI as-
sessment and digital examination or rigid sigmoidos-
copy for localization of the tumour at surgery.
We recommend full bowel preparation for any total
mesorectal resection to prevent ongoing pelvic sepsis
in a defunctioned patient from the column of fae-
ces that will be left from an unprepared colon. Care
needs to be taken to ensure that this is carefully docu-
mented and communicated to the ward and nursing
staff, as bowel preparation is not routine, especially
for patients in enhanced recovery programmes. All
our patients having open or laparoscopic TME are
counselled and sited preoperatively for a defunction-
ing right-sided ileostomy and left iliac fossa colostomy.
Operation Table Positioning
The patient is placed supine on an electrically oper-
ated table, with the legs in a modified Lloyd Davies
08/02/13 5:50 PM
 146  Laparoscopic surgery
Figure 9.1 Modified Lloyd Davies
position of legs.
position. The legs are placed in leg supports, often
requiring additional foam padding behind the calf.
This may be placed laterally to reduce the risk of
common perineal nerve compression. The legs are
abducted with the knees at shoulder width apart
and flexed to approximately 708. To prevent the
right thigh getting in the way of the right hand of
the operating surgeon, the hips are placed in neu-
tral or slight extension (Figure 9.1).
All patients have bladder catheterization and a
nasogastric tube.
Port Insertion and Positioning
The surgeon stands to the patient’s right, with the
camera holder on the same side to the left of the
operating surgeon. The assistant stands to the pa-
tient’s left. For mobilization of the splenic flexure,
it is often useful for the operating surgeon to stand
between the patient’s legs and the assistant to stand
to the patient’s right.
We commonly use four ports for an anterior re-
section. The first port is normally placed just below
the umbilicus. Occasionally, if the distance from
umbilicus to symphysis pubis is short, this port may
be placed above the umbilicus. This port is placed
using an open or Hasson technique to minimize the
risk of injuring intra-abdominal viscera upon in-
sertion. A 10-mm balloon port is our preference at
HEBK001-C09_p140-153.indd 146
the umbilicus. This minimizes both gas leak and the
distance of extension of the port into the abdomen.
A second 10–12-mm port is placed just medial and
superior to the anterior superior iliac spine, with
a 5-mm port at least a hand’s breadth cephalad. A
further 5-mm port is placed laterally to the umbili-
cus on the left side of the patient. This is used as an
assisting port to provide retraction to the sigmoid
colon, and as an operating port (Figure 9.2).
Extra ports are introduced as necessary. A 10-mm
suprapubic port at the specimen extraction site can
be useful if the small bowel is difficult to position,
as the camera can be used through this port to give
a good view of the omentum and small bowel in
the upper abdomen and right upper quadrant. In
addition, this port can be used to provide addi-
tional retraction in the pelvis. A further right upper
quadrant port may be necessary to retract the small
bowel or help with splenic flexure mobilization in
large patients (see Figure 9.2).
Laparoscopy
The first step is to perform a diagnostic laparoscopy
and assess the abdomen. This involves evaluation
of:
l the tumour itself;
l the surface of the liver for liver metastasis;
08/02/13 5:50 PM
 OUR APPROACH TO LAPAROSCOPIC ANTERIOR RESECTION  147

Transverse Colon

IMV
5

5 DJ flexure
12 5

12

Figure 9.3 Medial approach to the splenic flexure.

12

Figure 9.2 Standard ports are shown in blue and optional

(Figure 9.5). This allows the transverse meso-
extra ports in green. colon to be mobilized off the pancreas. The vein is
then lifted and the two areas of dissection can be
connected to allow a medial to lateral dissection
out over Gerota’s fascia and the pancreas up to the
l the peritoneal surfaces and abdominal cavity
splenic flexure.
for small volume peritoneal disease;
The omentum is then detached from the trans-
l the splenic flexure to assess the need for mobi-
verse colon, which can usually be achieved by sharp
lization. Generally we have a low threshold for
dissection with scissors and diathermy. In patients
fully mobilizing the splenic flexure and would do
who are obese, it may be easier to divide the gas-
this initially as in open surgery. We do not feel
trocolic ligament with LigaSure™, starting medially
that mobilization is obligatory for all patients,
and entering the lesser sac from above and moving
e.g. in the case of a long sigmoid loop, it may be
out laterally.
feasible to omit splenic flexure mobilization.
Finally, the lateral attachments of the descending
colon and splenic flexure are divided to complete
Splenic Flexure Mobilization the mobilization.
Splenic flexure mobilization can be challeng-
Positioning ing, and sometimes moving the point of dissection
The patient is positioned flat or in the reverse Trende-
lenburg position to allow the small bowel to fall into
the pelvis. The omentum is retracted cephalad, above Ascending left colic
Pancreas vein
the liver and spleen. Some right tilt can be useful to
encourage the small bowel mesentery to fall to the
right to allow identification of the duodenal-jejunal
flexure and inferior mesenteric vein (Figure 9.3).
IMV
Approach
The inferior mesenteric vein is mobilized and divid-
ed above the ascending left colic vein as it dives be-
low the pancreas. We use either clips or ­LigaSure™
bipolar diathermy to divide the vein (Figure 9.4).
The lesser sac is opened above the pancreas and
lateral to the middle colic vessels. Figure 9.4 High division of the IMV.

HEBK001-C09_p140-153.indd 147 08/02/13 5:50 PM

 148  Laparoscopic surgery
transverse mesocolon
lesser sac
pancreas
Figure 9.5. Medial approach to the lesser sac.
­ etween a combination of medial, lateral and superior
b
approaches is required to continue to make progress.
An alternative approach, when splenic flexure
mobilization is considered imperative, is to start
the operation with the patient in the right lateral
position. If this is the preferred approach, several
pointers that may be helpful are as follows:
l Mark the first port position in the left upper
quadrant midclavicular line just below the cos-
tal margin while the patient is prone. Particu-
larly in a patient with a pendulous abdomen,
the port placement site can be difficult to assess
when the patient is in the right lateral position.
l Have the patient positioned at about 70–808
(not at 908).
l Use two back supports at the level of the
scapula and the anterior superior iliac spine.
l Position the monitor above and lateral to the
patient’s left shoulder.
l The right knee and hip should be in slight flexion.
l Cushion between the patient’s legs.
Approach to the Inferior
Mesenteric Artery Pedicle
Positioning
The patient is placed in a steep Trendelenburg posi-
tion with the right lateral tilt left in place. The small
bowel needs to be moved into the right upper quad-
rant. Several tricks and tips can facilitate this:
l The omentum needs to be as cephalad as pos-
sible; the maximum degree of Trendelenburg is
HEBK001-C09_p140-153.indd 148
then required to allow gravity to assist the small
bowel in falling out of the pelvis.
l The small bowel mesentery needs to be ‘layered’,
right and cephalad. We achieve this with the
blunt graspers (Johan’s type) closed, using blunt
manipulation of the leaves of the small bowel
mesentery.
l The terminal ileum and appendix may need to
be mobilized if they are holding the small bowel
in the pelvis.
l If the small bowel persists in dropping into the
field of view, a tonsil swab can be helpful in
providing additional retraction. If this fails, a
right upper quadrant port can allow a grasper
to act as a retractor across the right iliac fossa.
Finally, if small bowel positioning is still elusive,
placing the camera through a 10- or 12-mm
suprapubic port allows a better view of the right
upper quadrant and more accurate positioning
of the small bowel and omentum.
Approach
The inferior mesenteric artery (IMA) is approached
from a medial direction. To facilitate visualization
of the IMA pedicle as it arises from the aorta, the
sigmoid colon is retracted superiorly and cephalad.
Avoid handling the bowel directly by grasping an
appendix epiploicae for retraction.
Dissection of the pedicle
The pelvic brim is identified and the dissection begun
at the sacral promontory. The peritoneum is incised
below and parallel to the ileocolic pedicle. Our prefer-
ence is to mark the peritoneal dissection plane with
closed diathermy scissors. The vascular space is then
opened using small downward movements with the
scissors. The peritoneal incision is extended in a ce-
phalad direction over the origin of the IMA. The aim
is to separate the mesenteric fat from the retroperito-
neum. Continuing in this direction, Toldt’s plane will
be reached (the plane between the posterior mesoco-
lon and the anterior retroperitoneal fascia). Once in
this plane, it is our preference to use a blunt dissec-
tor (e.g. with 5-mm LigaSure™) to extend the dissec-
tion laterally towards the abdominal wall. The correct
plane should be avascular and allows the hypogastric
nerves, gonadal vessels and ureter to be dropped back
posteriorly (Figure 9.6). If the bare belly of the psoas
muscle is visible, then the dissection plane is deep to
the ureter. It is imperative that the ureter is positively
08/02/13 5:50 PM
 OUR APPROACH TO LAPAROSCOPIC ANTERIOR RESECTION  149
IMA
left ureter
branches of hypogastic
plexus
Figure 9.6 Mobilizing the inferior mesenteric artery pedicle.
identified before division of the pedicle. If this has not
been possible, then a lateral approach may be helpful.
It is our preference to carefully dissect out the IMA
at its origin from the aorta and then apply two large
Haemolock™ clips (gold). Dividing between the
clips can be done with or without an energy device. If
the pedicle is particularly bulky, it may be necessary
to divide it with a laparoscopic stapler. A tonsil swab
can be left at the most lateral point of dissection,
above the ureter, to identify the plane when atten-
tion is turned to the lateral attachments. Following
division of the IMA, the dissection can be continued
in a cephalad direction (in Toldt’s plane) towards the
splenic flexure. A second low division of the inferior
mesenteric vein is then performed for complete mo-
bilization. Again, if in the correct plane, Gerota’s fas-
cia will be left intact and swept posteriorly. Dissection
is continued in this direction until the physical extent
of dissection is limited. Before taking down the lat-
eral attachments, ensure that the plane has also been
developed as far as is possible in an inferior direction.
To release the lateral attachments, the sigmoid colon
will need to be retracted in a medial direction. If a
tonsil swab was left in situ, it will be visible as the at-
tachments are taken down and the plane identified.
If the medial to lateral dissection was adequate, this
will be a thin layer.
Mobilization of the Rectum
Principles
The concept of TME revolves around retraction
and counter-traction26 to facilitate dissection in the
HEBK001-C09_p140-153.indd 149
mesorectal fascial plane. In laparoscopic surgery,
traction and counter-traction on the mesorectum, or
near the tumour, have to be performed with instru-
ments and may be more traumatic (less soft and sen-
sitive) than an expert surgeon’s hand. This may result
in transgression of the ‘holy plane’, which has been
shown to be associated with poorer outcomes.33,35
Using a tonsil swab underneath a Johan’s retrac-
tor can facilitate atraumatic retraction. Once the
plane is opened up, air will enter the areolar plane
and allow sharp dissection with either scissors or
hook diathermy. At all time, retraction needs to be
gentle and the peritoneal edges should be used for
retraction. The uterus, or the peritoneum above the
seminal vesicles, can be stitched up to the anterior
abdominal wall to facilitate retraction if necessary.
In addition, in female patients a ‘swab-on-a-stick’
in the vagina retracting it anteriorly may aid visu-
alization of the planes. It is important at all times
during mobilization to be aware of the position of
the tumour. A combination of digital examination
before and during the procedure, and a review of
the preoperative MRI, are essential to compensate
for the loss of tactile sensation at laparoscopic sur-
gery compared with open surgery.
Technique
The peritoneum can then be incised towards the
pelvis, over the pelvic brim. Here it is important to
identify the ‘holy plane’ or mesorectal fascial plane
(Figure 9.7). The rectum is initially retracted anteri-
orly. This should be achieved with minimal trauma,
particularly at the level of the tumour.
rectum
TME plane
hypogastric plexus
Figure 9.7 Entering the total mesorectal excision plane at
the top of the pelvis.
08/02/13 5:50 PM
 150  Laparoscopic surgery
uterus
rectum retracted to left
holy plane
right hypogastric
nerve
Figure 9.8 Dropping back the right hypogastric nerve.
Care must be taken not to damage the hypogas-
tric nerves as they descend over the sacral promon-
tory into the pelvis. Dissection is continued in the
TME plane posteriorly and laterally, focusing ini-
tially on the right side (Figure 9.8).
When adequate mobilization on the right and
posteriorly has been achieved, the peritoneum on
the left can be divided carefully, dropping back the
left hypogastric nerve (Figure 9.9).
The rectum needs to be fully mobilized poste-
riorly with division of Waldeyer’s fascia and mo-
bilized off the pelvic floor. The same principles
apply as in open surgery, namely working down
the back of the rectum and coming round to the
sides with traction and counter-traction, often
with a tonsil swab demonstrating the planes
(Figure 9.10). As in open surgery, it is necessary
to move the focus of the dissection from right
uterus
left hypogastric nerve
rectum
Figure 9.9 Dividing peritoneum on the left.
HEBK001-C09_p140-153.indd 150
rectum
swab retractor
TME plane at back
Figure 9.10 Use of a swab as retractor.
lateral to left lateral or anteriorly to facilitate
distal dissection.
Anteriorly, in both male and female patients, a cuff
of anterior peritoneum should be preserved by con-
tinuing the dissection from the left and right sides and
meeting in the middle. This acts as a safe area to grasp
with a retractor and allows the surgeon to find the
correct plane behind the seminal vesicles in male pa-
tients and the vagina in female patients (Figure 9.11).
On the lateral pelvic side-wall the nervi erigentes
and inferior hypogastric plexus are dropped off
the rectum. The dissection should continue until
1–2 cm clear of the distal extent of the tumour, with
at least 5 cm of mesorectum below the tumour or
a total mesorectal excision. For TME, the rectum
needs to be completely mobilized off the pelvic
floor and on to the muscle tube as it enters the in-
tersphincteric groove (Figure 9.12).
vagina
cul de sac
Figure 9.11 Dissecting the rectovaginal plane.
08/02/13 5:50 PM

inferior hypogastric plexus
vagina
pelvic floor
rectum
Figure 9.12 Approaching the intersphincteric plane on the
left.
Division of the Rectum
and Anastomosis
It is our practice to strive to perform the same op-
eration laparoscopically as at open surgery, and
therefore a rectal washout after cross-clamping and
before rectal transection is imperative. Although
washout is a simple procedure at open surgery, it
is more complex laparoscopically due to difficulty
in occluding the lumen distal to the tumour. A
number of methods have been reported, including
the use of a bulldog clip or Roeder knot or passing a
piece of intravenous line tubing (or similar) via the
left iliac fossa port, around the rectum and using
this as an occlusive tourniquet.41 These techniques
are technically challenging in many cases and po-
tentially result in the procedure being abandoned
and washout not performed.
Following washout, the rectal transection can be
performed. Rectal transection proximal to the pel-
vic floor can be challenging, as current laparoscopic
staplers can angulate to a maximum of only 658. As
in open surgery, the transection should be perpen-
dicular to the rectal muscle tube. Ideally, this should
be achieved with a single firing of the stapler, but
practically it often requires two or three firings. Not
only is this expensive and time-consuming, but it
can also result in ‘dog ears’ or a zigzag transection
staple line, raising the possibility of ischaemic areas
that may subsequently increase the risk of leak. Fur-
thermore, within the confines of the narrow male
pelvis, especially for a mid- or low rectal cancer, it
HEBK001-C09_p140-153.indd 151
CONCLUSION  151
may be impossible to angulate the stapler across
the rectum. The inability to accurately palpate and
correctly identify the lower limit of the tumour
makes mesorectal transection for lower tumours
technically difficult. If there is still uncertainty, a
rigid sigmoidoscope, or digital examination in low
tumours, can be used to accurately determine the
point of transection.
If there is still uncertainty despite these manoeu-
vres, then it is our preference to insert the linear sta-
pler via a Pfannenstiel incision; this incision is also
used as the specimen extraction site. If the rectum
has been fully mobilized, the stapler can be applied
easily through an 8-cm incision and also facilitates
formation of a defunctioning ileostomy.
Specimen Extraction
To facilitate specimen location and retrieval, we
leave a Johan’s retractor attached to the divided
bowel end. If not performed already for cross-sta-
pling, our preferred extraction site is via a Pfan-
nenstiel incision. The patient should be left in the
head-down position while the abdominal inci-
sion is made. A wound retractor is inserted; we
currently favour the Alexis (Applied Medical)™
wound system. The bowel is removed and the
proximal resection point identified. The anvil of
the circular stapler can be inserted in the normal
fashion, before dropping back into the abdomen,
restoring the pneumoperitoneum and performing
the anastomosis.
CONCLUSION
In summary, with regard to the ‘abdominal’ part
of a rectal cancer operation, it is likely that a
laparoscopic minimal-access technique is feasible
and beneficial, in the short term, although operat-
ing time may be prolonged. Equipment costs may
be greater, but the shorter hospital stay and faster
recovery may more than compensate for these
additional initial expenses.
Initial randomized controlled trials report
equivalence in longer-term oncological outcomes,
with some groups reporting comparable local re-
currence rates. The advantage of magnification of
the TME plane may give better visualization and
08/02/13 5:50 PM
 152  Laparoscopic surgery
s­ ubsequently better macroscopic quality of the
specimen, particularly when surgeons and operative
teams have overcome the learning curve and gained
experience. Ultimately, the individual surgeon’s ap-
proach to rectal cancer surgery will be determined
by many factors. Each case has to be assessed on an
individual basis, taking into account patient fac-
tors, anatomical considerations and the experience
of the individual surgeon. The surgeon should also
be willing to change the approach intraoperatively
if there is any concern about the oncological out-
come being compromised. Each surgeon should
audit their laparoscopic rectal cancer outcomes and
compare these with their outcomes from open sur-
gery. Longer-term outcome data from clinical tri-
als are awaited to answer some ongoing issues, such
as long-term cure rates, incisional hernia rates and
postoperative adhesions.
The data suggest that optimal oncological colorectal
cancer resection can be performed laparoscopically
in selected patients. Nevertheless, there are still some
ongoing concerns regarding laparoscopic low ante-
rior resection. The group that described the first
rectal cancer resection have reported higher than
expected local recurrence rates in Union for Inter-
national Cancer Control (UICC) stage III disease.42
Achieving good oncological outcomes for mid- and
low rectal cancer is a continuing challenge, regard-
less of whether the approach is open or laparoscop-
ic. Good-quality surgery, according to the experi-
ence and technical ability of the surgeon, should be
the gold standard. Whether the marginal short-term
benefits of the laparoscopic approach justify the po-
tential oncological downside remains controversial.5
In rectal cancer surgery, safe retraction and counter-
traction, an optimal view, good-quality adherence to
the TME ‘holy plane’ principles, optimal mesorec-
tal excision or transection, and rectal division and
anastomosis remain the aim in this common, often
complex cancer.
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08/02/13 5:50 PM

Robotic total mesorectal excision
M. Chadwick, H.S. Tilney and A.M. Gudgeon
Introduction
The da Vinci robot is a sophisticated tool for per-
forming minimal access surgery. The actions of the
instruments are entirely under the control of a sur-
geon seated separately from the patient. The camera
and instruments are controlled by hand and foot
movements of the surgeon. The surgeon can oper-
ate the instruments from a comfortable position,
with forearms supported and completely intuitive
reproduction of hand movements to the operating
instruments. The surgery is aided by high-definition
three-dimensional optics. The surgery may be per-
formed entirely using the robotic instruments or as
a hybrid procedure combining standard laparos-
copy with robotics.
History and development of
robotic colorectal surgery
Robots have been used in surgery since 1985, with
the PUMA 560 first assisting a brain biopsy. In
1988 the first prostatic surgery was performed by
the PROBOT at Imperial College, London. The first
robot for clinical use in general surgery was the au-
tomated endoscopic system for optimal positioning
(AESOP) (Computer Motion, Santa Barbara, CA,
USA). In 1994 the United States Food and Drug
Administration (FDA) approved AESOP for clini-
cal use as a robotic camera-holder. In 1990 the De-
fence Advanced Research Projects Administration
HEBK001-C10_p154-170.indd 154
10
supported the development of a prototype robot by
SRI International because of its potential to allow
surgeons to operate remotely on soldiers wounded
on the battlefield. As a result of this, in 1995 Intui-
tive Surgical Devices Inc. came into being; taking
this prototype forward, the da Vinci system evolved.
It was first tested in 1997 and then marketed in
­Europe in 1999. Sales in the USA were soon to fol-
low in 2000, with FDA approval for general laparo-
scopic surgery. The ZEUS robotic surgical system
developed by the rival company Computer Motion
allowed the first telerobotic surgery in 2001, with
the surgeon in New York and the patient in France.
Fierce competition stalled further developments
until, in 2003, Intuitive Surgical and Computer
Motion merged and the ZEUS system was phased
out in favour of the da Vinci system, which is now
used across the world, particularly in South Korea,
the USA and Europe. The latest refinement is the da
Vinci Si, released in 2009.
The most common procedure performed with
the da Vinci system is radical prostatectomy, but
many other urological, gynaecological, cardiotho-
racic, paediatric and general surgical procedures
have been performed, including pyeloplasty, cystec-
tomy, nephrectomy, ureteral reimplantation, hyster-
ectomy, myomectomy, sacrocolpopexy, mitral valve
repair, atrial septal defect closure, cardiac bypass,
ablation, mediastinal tumour excision, cholecys-
tectomy,1 Nissen fundoplication, Heller myotomy,
gastric bypass, donor nephrectomy, adrenalectomy,
splenectomy and hepatic resection.2
11/02/13 3:58 PM

The uptake of robotic colorectal surgery has been
relatively recent. Most work has been done in South
Korea, but increasing numbers of procedures are
being performed in Italy and the USA, and its use
is gradually expanding in a few centres in the UK.
Procedures include right and left hemicolectomy,
total mesorectal excision (TME), proctectomy and
ileal pouch–anal anastomoses, and ventral mesh
rectopexy. With increasing experience, confidence is
building and increasingly advanced procedures are
being performed. In 2007 Baik and colleagues re-
ported simultaneous robotic TME, total abdominal
hysterectomy for rectal cancer and uterine myoma.3
In 2009 Patriti and colleagues reported a series of
robotic colectomies, including one rectal resection
with synchronous hepatic metastatectomies.4
In 2002 Weber and colleagues reported three
robotic right and sigmoid colectomies for benign
disease using the da Vinci robotic system.5 In the
following year, Delaney and colleagues compared
robot-assisted laparoscopic colectomy with case-
matched results using standard laparoscopic ap-
proaches, focusing on clinical outcomes.6 Despite
only six robotic colectomies being performed be-
tween December 2001 and April 2002, there were
conclusions of feasibility and safety of the da Vinci
system. D’Annibale and colleagues reported 53 ro-
botic colorectal cases from May 2001 to May 2003,
including 22 patients with malignant disease.7 They
concluded that robotic techniques could achieve the
same operative and postoperative results as conven-
tional laparoscopic surgery. Rawlings and colleagues
reported 30 consecutive robotic cases;8 the series
included 17 right hemicolectomies and 13 anterior
resections, with the conclusion that robotic surgery
is technically feasible using the da Vinci system. Two
years later the same authors reported the results
comparing robotic with laparoscopic colectomy.9
The outcome in each group was similar.
ROBOTIC RECTAL SURGERY
Robotic low anterior resection is performed in only
a few centres worldwide. Surgery for rectal cancer is
more difficult than colonic surgery because of the
anatomical characteristics of the rectum and the
pelvis. The principle underlying TME is precise dis-
section of an avascular plane between the presacral
fascia and the fascia propria of the mesorectum.
HEBK001-C10_p154-170.indd 155
ROBOTIC RECTAL SURGERY  155
The view of the surgical field is limited within the
pelvis during TME, particularly when operating in
the narrow male pelvis, and this may have an im-
pact on the quality of the resected mesorectum.10
The most important factor relating to rectal dissec-
tion is the grade of the mesorectal specimen, which
in turn is closely related to oncological outcome.11,12
A good view is mandatory if precise mesorectal
dissection is to be successful. The ability of the da
Vinci surgical system to offer a three-dimensional
view with magnification, filtering of hand tremor,
fine dexterity and motion scaling suggests the po-
tential for a technical surgical advantage over open
or laparoscopic TME.
A four-arm technique for robotic TME has been
summarized by Baik and colleagues.13 The instru-
ments used for dissection were a Cadiere grasper,
a PreCise™ Bipolar grasper and a permanent cau-
tery spatula. The Cadiere grasper provides the first
traction and the PreCise Bipolar grasper provides
the second proper traction. Moreover, these grasp-
ers can change to an L-shaped small retractor using
the EndoWrist™ function that is the core technol-
ogy of the da Vinci system. The robotic instrument
can be used not only to create traction by grasping
tissue but also to push the tissue in the narrow pel-
vic space, thereby achieving traction and counter-
traction to expose the ideal tissue planes. The com-
bination of traction and counter-traction using the
robotic instruments can provide an excellent surgi-
cal view during the rectal dissection in a confined
space.
Evolution of Robotic Total Mesorectal
Excision
Until now, most studies relating to robotic low an-
terior resection have reported only initial experi-
ences. The sample sizes have been small and they
are generally non-randomized. Larger, randomized
studies are necessary to assess the feasibility of the
robotic system and whether there are real benefits
of the robotic system compared with conventional
laparoscopic surgery.
Tables 10.1–10.3 summarize the results of ex-
isting studies comparing outcomes between ro-
botic and laparoscopic rectal resections. In 2004
D’Annibale and colleagues compared 12 robotic
rectal resections with laparoscopic rectal resection
11/02/13 3:58 PM
HEBK001-C10_p154-170.indd 156

156  Robotic total mesorectal excision

Table 10.1. Overall characteristics of studies reporting outcomes of robotic rectal cancer surgery.
Period
Study Institution of study Type of study Patients (n) Procedures (n)
Robotic Laparoscopic
surgery surgery Robotic surgery Laparoscopic surgery
Delaney et al. 6
Cleveland Clinic, 2001–2002 Case-matched 6 6 Right hemicolectomy (2), sigmoid Right hemicolectomy (2), sigmoid
OH, USA resection (3), rectopexy (1) resection (3), rectopexy (1)
D’Annibale et al.7 Padova, Italy 2001–2003 Case-matched 53 53 Right hemicolectomy (10), ileocaecal Right hemicolectomy (13), ileocaecal
resection (0), transverse colectomy (0), resection (1), transverse colectomy (1),
left hemicolectomy (17), sigmoid left hemicolectomy (17),
resection (11), sigmoid resection (4), anterior
anterior resection (10), abdominoperineal resection (15), abdominoperineal
excision of rectum (1), excision of rectum (0),
total colectomy (2), Hartmann’s (1), total colectomy (1), Hartmann’s (1),
Hartmann reversal (0), rectopexy (1) Hartmann reversal (2), rectopexy (0)
Pigazzi et al. 14†
City of Hope National 2004–2005 Non-randomized, 6 6 Low anterior resection Low anterior resection
Medical Center, comparative
CA, USA
Hellan et al.15† City of Hope National 2004–2007 Case series 39 – Rectal cancers: low anterior resection (22), –
Medical Center, coloanal (11), abdominoperineal excision
CA, USA of rectum (6)
Baek et al.16† City of Hope National 2004–2008 Case series 64 – Rectal cancers: colorectal anastomosis (34), –
Medical Center, coloanal anastomosis (18), abdominoperineal
CA, USA excision of rectum (12)
Spinoglio et al. 19
Alessandria, Italy 2005–2007 Non-randomized, 50 161 Right hemicolectomy (18), left hemicolectomy Right hemicolectomy (50), left
comparative (10), anterior resection (19), abdominoperineal hemicolectomy (73), anterior resection
excision of rectum (1), transverse colectomy (1), (26), abdominoperineal excision of
total colectomy (1) rectum (7), transverse
colectomy (2),
total colectomy (3)

(Continues)
11/02/13 3:58 PM
HEBK001-C10_p154-170.indd 157

Table 10.1. Overall characteristics of studies reporting outcomes of robotic rectal cancer surgery. (Continued)

Period
Study Institution of study Type of study Patients (n) Procedures (n)
Robotic Laparoscopic
surgery surgery Robotic surgery Laparoscopic surgery
Baik et al.13* Seoul, South Korea 2006–2007 Case series 9 – Total mesorectal excision –

Baik et al.20* Seoul, South Korea 2006–2007 Randomized 18 18 ‘Tumour-specific total mesorectal ‘Tumour-specific total mesorectal
controlled trial excision’ excision’
Baik et al. *
21
Seoul, South Korea 2006–2007 Non-randomized, 56 57 Low anterior resection Low anterior resection
comparative
Choi et al.22 Korea University Anam 2007–2008 Case series 50 – Rectal cancers –
Hospital, Seoul,
South Korea
Luca et al.23 Milan, Italy 2007–2008 Case series 55 – Anterior resection (17), abdominoperineal –

ROBOTIC RECTAL SURGERY  157

excision of rectum (7), coloanal (4),
left hemicolectomy (27)

*Multiple publications by the same departments with likely duplication of reported outcomes.
†,
11/02/13 3:58 PM
HEBK001-C10_p154-170.indd 158

158  Robotic total mesorectal excision

Table 10.2. Short-term outcomes from studies reporting outcomes of robotic rectal cancer surgery.
Duration of surgery (min) Length of stay (days) Anastomotic
Study Conversion (range)a Blood loss (mL) (range)a (range) leak Complications
Robotic Laparoscopic Robotic Laparoscopic Robotic Laparoscopic Robotic Laparoscopic Robotic Laparoscopic Robotic Laparoscopic
surgery surgery surgery surgery surgery surgery surgery surgery surgery surgery surgery surgery
Delaney – – 216.5 150 (116–165) 100 87.5 (50–200) 3 (2–5) 2.5 (2–7) – – 1 atelectasis 1 incisional
et al.6 (170–274) (50–350) hernia

D’Annibale 6 (2 to 3 240 (661) 222 (677) 21 (680) 37 (6102) – – 0 1 2 bowel injuries, 1

et al.7 laparoscopy, CVA, 1 wound

4 to hand- infection
assisted
laparoscopy)
Pigazzi – – 264 (192–318) 258 (198–312) 104 150 (50–300) 4.5 (3–11) 3.6 (3–6) – – 1 prolonged ileus 1 pelvic abscess
et al.14† (50–318)

Hellan – – 285 – 200 – 4 (2–22) – 4 (12.1%) – 1 intraoperative –

et al.15† (180–540) (25–6000) bleed, 2 wound

infections

Baek 6 (9.4%) – 270 (150–540) – 200 – 5 (2–33) – 4 (7.7%) – 4 pelvic

et al.16† (20–6000) abscesses

Spinoglio 2 (1 to 4 383.8b 266.3b – – 7.74 8.31 2 – 1 incisional hernia, –

et al.18 laparoscopy, 1 atelectasis,

1 to 1 wound
laparotomy) infection,
1 phlebitis,
1 CVA
Baik 0 – 213 (153–315) – – – 7 (5–10) – – –
et al.13*

Baik 0 2 202.5 196.0 (114–297) – – 7 (5–10)b 9 (6–12)b – – – –

et al.20* (149–315)

Baik 0b 6b 178 (120–315) 179 (100–360) – – 5 (5–10)b 6 (4–16)b 1 4 ‘Serious ‘Serious

et al.21* complication’ complication’
5.4%b 19.3%b
(Continues)
11/02/13 3:58 PM
 ROBOTIC RECTAL SURGERY  159

and demonstrated that robotic and laparoscopic

Laparoscopic
techniques could achieve the same operative and

surgery
postoperative results.7 Pigazzi and colleagues com-

Complications
pared short-term outcomes between robotic TME

–
and laparoscopic TME and concluded that robotic
low anterior resection with TME and autonomic
nerve preservation was possible.14 The same group
Robotic
surgery
–
subsequently reported a series of 39 consecutive

–
unselected patients with primary rectal cancer and
Laparoscopic

concluded that robotic-assisted surgery for rectal

Figures for continuous outcomes represent median values with range in parentheses unless 6 stated, which denotes standard deviation.
cancer could be carried out safely.15
surgery
Anastomotic

Baik and colleagues reported the first Asian expe-

leak

rience of robotic total mesorectal excision for rectal

–

cancer patients in June 2006.17 The first published

Robotic
surgery
4 (8.3%)

case of robotic abdominoperineal resection in Asia

was performed in Hong Kong in August 2006.18
–

One study including 20 robotic rectal cancer exci-

Laparoscopic
Length of stay (days)

sions concluded that robotic colonic surgery was fea-

surgery

sible and safe. Spinoglio and colleagues reported a sig-

Table 10.2. Short-term outcomes from studies reporting outcomes of robotic rectal cancer surgery. (Continued)

(range)

nificant increase in operating time (see Table 10.2),19

–

but in the authors’ experience this length reduces with

(4–17)
Robotic

(5–24)
surgery

experience as ‘docking time’ reduces. The use of a hy-

brid technique to perform vascular division and left
7.5
9.2

*Multiple publications by the same departments with likely duplication of reported outcomes.

colon/splenic flexure mobilization laparoscopically

Laparoscopic
Blood loss (mL) (range)a

can also help to reduce operative times.

Baik and colleagues launched the first prospec-
surgery

tive randomized trial of robotic versus laparoscopic

–

low anterior resection in 2006.20 The short-term

outcomes of this pilot study comparing 18 robotic
(0–600)
Robotic
surgery

low anterior resections with 18 laparoscopic cases

68

highlighted the feasibility and safety of robotic

–

low anterior resection. A trend towards a superior

Laparoscopic
Duration of surgery (min)

mesorectal grade in the robotic low anterior resec-

surgery

tion group did not achieve statistical significance,

(range)a

but macroscopic grading of the robotic group

–

showed the mesorectum to be complete in 17 cases

(190–485)

(164–487)

and nearly complete in 1 case. Similar results were

Robotic
surgery

shown in their larger, albeit non-randomized,

304.8

290

comparative study from 2008.23 The quality of the

resected specimen can be considered a surrogate
Laparoscopic

marker for both surgical quality and outcome.24 If

surgery

this can be shown to achieve significance in ongo-

CVA, cerebrovascular accident.
Statistically significant results.
Conversion

ing trials, then it would support a potential onco-

–

logical benefit for robotic rectal cancer surgery, in

oncological terms. In addition, the use of sharp dis-
Robotic
surgery

section and simple diathermy in the avascular TME

plane may aid identification and preservation of the
0
–

pelvic autonomic nerves and therefore represent a

secondary benefit in terms of long-term quality-of-
et al.22
et al.2
Study

Luca

life outcomes.
Choi

†,
b
a

HEBK001-C10_p154-170.indd 159 11/02/13 3:58 PM

HEBK001-C10_p154-170.indd 160

160  Robotic total mesorectal excision

Table 10.3. Oncological outcomes from studies reporting outcomes of robotic rectal cancer surgery.
Circumferential
Lymph node yield (n) resection margin
Study (range)a Distal resection margin (cm) Total mesorectal excision assessment involvementb
Robotic Laparoscopic Robotic surgery Laparoscopic Robotic surgery Laparoscopic surgery Robotic Laparoscopic
surgery surgery surgery surgery surgery
Delaney et al. 6
– – – – – – – –
D’Annibale et al.7 17 (610) 16 (69) – – – – – –
Pigazzi et al.14† 14 (9–28) 17 (9–39) 3.8 (1.8–9) 3.5 (2.2–5) – – – –
Hellan et al.15† 13 (7–28) – 2.65 (0.4–7.5) – – – 0 –
Baek et al.16† 14.5 (3–28) – 3.4 (0.2–10) – – – 0 –
Spinoglio et al. 18
22.03 22.85 7.3 7.9 – – – –
Baik et al.13* 22 (2–31) – 2.5 (1–6.5) – Complete (8), nearly complete (1) – – –
Baik et al.20* 18 (6–49) 22 (9–42) 4 (1–5.5) 3.5 (1.5–6.0) Complete (17), nearly complete (1) Complete (13), nearly complete (5) – –
Baik et al. *
21
17.5 (4–43) 17 (4–53) 4 (1–7) 3 (1–9) Complete (52), nearly complete (4), Complete (43), nearly complete 4 5
incomplete (0) (12), incomplete (2)
Choi et al.2 20.6 (4–48) – 1.9 (0.5–4.5) – – – 1 –
Luca et al.22 – – – – – – – –
a
Figures for continuous outcomes represent median values with range in parentheses unless 6 stated, which denotes standard deviation.
b
tumour #1 mm from circumferential cut edge.
†,
*Multiple publications by the same departments with likely duplication of reported outcomes.
11/02/13 3:58 PM

Overall, few studies have shown substantial
differences in short-term outcomes between ro-
botic and laparoscopic resections (Tables 10.1
and 10.2). Two studies from the same unit have
revealed a significant reduction in length of stay
and ­‘serious complications’ in patients undergo-
ing robotic surgery, but most of these small, and
almost exclusively non-randomized, studies have
shown ­robotic surgery to be at least as safe as, and
oncologically equivalent to, laparoscopic surgery
(see Table 10.3).18,24 There is a need for further
exploration in large-scale randomized trials to de-
termine whether robot-assisted TME is superior
in oncological and quality-of-life terms to laparo-
scopic and open surgery.
Patient Preparation
The preoperative work-up for a patient with rec-
tal cancer begins with a full history and physi-
cal examination. Blood tests should include a full
blood count, electrolytes, liver function tests, car-
cinoembryonic antigen (CEA) levels and a 2 unit
cross-match. In our experience, blood transfusion
is rarely required during laparoscopic or robotic
rectal cancer surgery, but it must be remembered
that if serious bleeding occurs undocking the ro-
bot can lead to delays in controlling the bleeding
point. An electrocardiogram is requested; where
appropriate, cardiopulmonary exercise testing is in-
creasingly used to help to stratify operative risk and
optimize perioperative management. Full colonic
imaging by colonoscopy, barium enema or com-
puted tomographic (CT) pneumocolon evaluation
is performed to exclude synchronous tumours, and
histological diagnosis is confirmed on biopsy. The
distance from the lower border of the tumour to
the anal verge is measured using rigid sigmoidos-
copy; accurate measurement is essential for surgical
planning. Clinical evaluation of sphincter tone and
careful assessment of premorbid anorectal function
may help to identify patients in whom a low anas-
tomosis would lead to unacceptable postoperative
outcomes. Computed tomography of the chest, ab-
domen and pelvis is performed to assess for distant
metastases and local disease infiltration.
The rectal cancer is staged by pelvic magnetic
resonance imaging (MRI) to measure the extent of
local infiltration and identify patients with threat-
HEBK001-C10_p154-170.indd 161
ROBOTIC RECTAL SURGERY  161
ened resection margins(see Chapter 4). Endolumi-
nal ultrasound (see Chapter 3) can help to differen-
tiate between T1 and T2 tumours.
In the authors’ unit, all patients undergoing TME
with anastomosis have preoperative oral mechani-
cal bowel preparation and a defunctioning loop ile-
ostomy. Patients are counselled and sited by a stoma
therapist preoperatively.
Position
The patient is most commonly placed in a modi-
fied Lloyd Davies position, with the hips slightly ex-
tended and the knees flexed to 70–908 and placed just
greater than shoulder width apart. In our experience,
the use of a body-length gel mat in direct contact
with the patient’s skin keeps the patient safely on the
operating table without the need for shoulder sup-
ports. Thromboembolic deterrent stockings (unless
contraindicated) and intermittent calf compression
are used routinely. A warm air blanket is placed over
the patient’s chest. The arms are wrapped at the pa-
tient’s sides and protected from the metalwork of the
table. The patient is catheterized.
Some surgeons prefer to use a lateral approach
to the splenic flexure, in which case the patient is
positioned accordingly – left side uppermost, with
the hips straight and knees bent. Lateral supports
are necessary against the patient’s back. A left arm
support gutter is also used. (If the hips are flexed,
the left thigh will hinder the smooth and efficient
use of instruments via the left lateral port.) After
mobilizing the splenic flexure, the patient is turned
on to the back and positioned in the Lloyd Davies
position, as described above.
Surgical Approach
The authors favour routine mobilization of the splenic
flexure when performing an anterior resection with
TME. This is done at the start of the procedure as it
is often technically difficult. Once completed, there is
no temptation to compromise if the rectal dissection
proves difficult and time-consuming. Although mobi-
lization of the splenic flexure and left colon with high
ligation of the inferior mesenteric artery and vein can
be performed using the da Vinci system, the authors
favour a hybrid approach, with standard laparoscopy
11/02/13 3:58 PM
 162  Robotic total mesorectal excision
for the abdominal component of the operation fol-
lowed by robotic rectal dissection.
Port sites
The optimum port siting is the subject of much
conjecture, and many arrays of ‘standardized’ port
site are described. The authors’ preferred set-up has
evolved from assessment of the published techniques
and as a result of trial and error. A compromise in
placement is required to facilitate safe and efficient
laparoscopic mobilization, while still allowing effec-
tive robotic instrument use in the pelvis, if the over-
all number of port sites is to be minimized. A report
by Luca and colleagues describes a port site set-up
that allows for complete low anterior resection and
does not require the robot cart to be moved.25 The
authors’ favoured sites are as follows:
A supraumbilical incision is made and a 12-mm
internal diameter port is inserted using an open Has-
san technique to accommodate the large-diameter
three-dimensional robotic telescope and camera.
The pneumoperitoneum is established with an in-
sufflation pressure set to 12–15 cmH2O. A 10-mm
laparoscope is used to assess the feasibility of a min-
imal access approach in terms of adhesions, adipos-
ity of the abdominal wall and mesenteries, and ana-
tomical anomalies, which may hinder or prevent
progress. The procedure continues by insertion of
the operating and assisting robotic 8-mm ports.
These are inserted under direct vision via marked
skin incisions positioned optimally to avoid clash-
ing of the robotic arms. A minimum of 8 cm is rec-
ommended between ports.
The robotic cannulae are marked with broad
black bands that represent the fulcrums for angu-
lation. These should lie just within the abdominal
wall to allow effective movement and minimize
postoperative pain.
The authors favour the use of robotic ports in
standardized positions during the laparoscopic part
of the procedure. An additional 12-mm port in the
right iliac fossa, 3–4 cm inferomedial to the ante-
rior superior iliac spine, is used for laparoscopic
instrumentation and for assistant access during the
robotic phase of the procedure. This allows access
for clip applicators, suction/irrigation devices, in-
sertion and removal of tonsil and mastoid swabs,
and stapling devices.
Ports are sited to optimize triangulation of in-
struments, avoid clashing and provide maximum
HEBK001-C10_p154-170.indd 162
field of view. The camera port is therefore placed in
the mid-position of the instrumental port site arc,
ideally just above or to the right of the umbilicus,
so that the field of vision is centred on the mid-
line. The primary operative robotic 8-mm port is
placed on the right, 8–10 cm laterally along the arc
from the umbilicus to the right anterior superior
iliac spine. The secondary operative robotic 8-mm
port is placed 8–10 cm left laterally along the arc
from the umbilicus to the left anterior superior iliac
spine. The tertiary operative robotic 8-mm port
is placed 8–10 cm laterally to this along the same
arc at a site roughly corresponding to the 12-mm
laparoscopic assistant port opposite (Figure 10.1).
For a small patient, the second operating arm can
be placed a few centimetres cranially to maintain
optimum spacing between ports.
Right lateral approach to the splenic flexure
If a lateral approach is chosen, the first port to be
placed is in the left lateral port position using a
5-mm optical port, inside which a 5-mm laparo-
scope is used to enter the abdominal cavity under
A2
12 R2
R1
R3
A1
Figure 10.1. Robotic instrument ports R1, R2 and R3.
R1 is the main operating port, with traction and counter-
traction provided by R2 and R3. The 12-mm port is for the
camera just to the right of the umbilicus. A1 and A2 are
assistant ports. A1 is also used for stapling the rectum.
11/02/13 3:58 PM

vision. This port can be replaced later by the 8-mm
robotic port. The laparoscopy is performed and the
12-mm umbilical port can then be inserted under
direct vision. An additional 5-mm port is placed in
the left upper midclavicular line for the purposes of
laparoscopic splenic flexure mobilization.
Mobilization of the splenic flexure
The right lateral position for splenic flexure mo-
bilization is particularly useful in patients who are
obese, as the entire enteric mass falls away under
the influence of gravity; in some cases, the entire
lateral mobilization of the left colon down to the
pelvic brim can be achieved in this position. More
commonly, however, splenic flexure mobilization is
performed with the patient supine, tilted left side
up towards the operating surgeon. The small bowel
should fall away but may require gentle sweeping.
Occasionally, peritoneal adhesions prevent this and
require division to partially mobilize the duodeno-
jejunal flexure. Once the lateral border of the duo-
denojejunal flexure is clearly identified, the inferior
mesenteric vein can be identified running inferola-
terally within the left colonic mesentery.
The peritoneum is incised to allow identification
and isolation of the inferior mesenteric vein. The
vein is divided with an appropriate haemostatic
energy source, or between clips, at the level of the
lower border of the pancreas. Dissection continues
medial to lateral in the plane between the mesen-
tery and Gerota’s fascia towards the lateral abdomi-
nal wall. The lesser sac is entered just above the
body of the pancreas, where the left branch of the
middle colic artery marks the most medial aspect
of the dissection. The posterior wall of the stomach
is clearly seen superiorly, with the tail of the pan-
creas inferiorly and the transverse mesocolon an-
teriorly after its disconnection from the pancreas.
The splenic flexure and descending colon are ante-
rolateral. Lateral attachments of the descending co-
lon and splenic flexure are divided, and the flexure
is freed by re-entering the lesser sac from above by
dissecting the greater omentum free from the trans-
verse colon.
Division of inferior mesenteric artery and
sigmoid mobilization
The patient is placed in a steep head-down position,
with the right lateral tilt maintained. The omentum
is reflected over the liver and the mobilized flexure
HEBK001-C10_p154-170.indd 163
THE DA VINCI SURGICAL SYSTEM  163
placed back in the left upper quadrant. The small
bowel is gently swept out of the pelvis up into the right
upper quadrant. The pelvic brim is identified at the
sacral promontory, and the sigmoid colon is tented
up to reveal the fossa beneath the inferior mesenteric
artery (IMA) over the bifurcation of the aorta.
The peritoneum is incised along a broad front
to allow entry into, and then medial to lateral dis-
section within, Toldt’s plane. The retroperitoneal
structures are carefully swept posteriorly, preserv-
ing the left ureter and gonadal vessels. Once these
are identified and preserved, attention is focused on
isolation of the IMA. Taken high, this allows for a
single vessel division. It is important to identify and
preserve the pre-aortic sympathetic nerves at this
point and to avoid taking the vessel flush with the
aorta, as this may cause nerve damage. There are
many ways to secure the artery, including clips, sta-
pling devices and energy instruments. When taken
more distally, the ascending left colic artery and sig-
moid branches may be encountered, necessitating
further dissection and separate vessel division.
The dissection is continued in Toldt’s plane as far
out laterally as the abdominal wall and cranially un-
til the previously dissected descending colonic me-
sentery is reached. Inferiorly, the dissection reaches
the plane between the mesorectal fascia and the pel-
vic parietal fascia. The lateral attachments are then
divided, taking particular care to avoid the left ure-
ter across the pelvic brim, such that the entire left
colon is then mobilized. It is then the authors’ pref-
erence to tie a nylon tape around the rectosigmoid
junction to facilitate retraction of the rectum out of
the pelvis during mesorectal dissection.
THE DA VINCI SURGICAL SYSTEM
The robotic system consists of three main compo-
nents: the operating console, the electronic tower
and the patient cart.
The console (Figure 10.2) is where the surgeon
controls the robotic arms and instruments. It com-
prises scissor-handle-type master controls, which
translate the surgeon’s hand movement directly to
the instrument tips, including the ‘wristing’ angu-
lation and rotation (Figure 10.3). There are foot
pedals for camera control, disengaging instruments
(clutch), focusing and the application of monopo-
lar and bipolar diathermy (Figure 10.4).
11/02/13 3:58 PM
 164  Robotic total mesorectal excision
Figure 10.2. Operating console.
The electronic tower holds the video-processing
system, light source and insufflation equipment. All
the electronics run through the control tower be-
tween the console and the patient cart. The cart also
has a high-definition screen to transmit a two-di-
mensional image of the operating field and allows a
trainer to draw lines on the screen to help a trainee
sitting at the console locate the correct planes of
dissection.
The patient-side cart consists of a powered trol-
ley holding three or four robotic arms (Figure 10.5).
The scrub nurse is responsible for preparing the robot
Figure 10.3. Hand controls for robotic
surgical instruments.
HEBK001-C10_p154-170.indd 164
cart with specially designed transparent sterile covers
(Figure 10.6). The stereoscopic scope, camera and
light lead are also prepared in a sterile fashion with a
special disposable outer sleeve.
There is a range of dedicated robotic instruments,
including dissectors, graspers and retractors. Where
appropriate, these instruments can be connected to
monopolar or bipolar diathermy sources. Each in-
strument has a lifespan of ten procedures. To mini-
mize cost, it is important to develop a technique
using as few instruments as possible. The authors
prefer the use of a diathermy hook or monopolar
diathermy scissors (‘hot shears’) in the right-side
operative port, Maryland bipolar forceps in the pri-
mary assistant port, and a large grasping retractor
or Cadiere forceps in the secondary assistant port.
The central robotic arm holds the camera. Arms 1,
2 and 3 hold the operating instruments introduced
through the 8-mm reusable robotic ports.
Set-Up of Robotic Total Mesorectal
Excision
The patient remains in a steep head-down right
lateral tilt to prevent the small bowel from falling
into the pelvis. In female patients with an intact
uterus, a straight-needled polypropylene suture is
driven through the suprapubic skin through the
fundus of the hitched-up uterus and back through
the suprapubic skin and tied over a swab to pre-
vent damage to the skin and to act as a reminder
to remove the suture at the end of the operation.
The authors find this gives better uterine eleva-
tion than lifting the uterus by the broad ligament
11/02/13 3:58 PM
 THE DA VINCI SURGICAL SYSTEM  165

Figure 10.4. Foot pedals.

and fallopian tubes and also requires only a single The role of the assistant is important and far
suture. from redundant. A scrubbed assistant knowledge-
able in the set-up and function of the da Vinci sys-
tem is absolutely essential to the smooth running
Positioning the Robot and efficiency of the procedure. Set-up (docking)
can be time-consuming and present risk to the pa-
The choice of robot docking position is entirely tient if not performed carefully and meticulously.
personal to the surgeon and will be influenced by The robot is carefully docked between the patient’s
both positive and negative experiences in terms of legs, and the laparoscopic instruments, including the
ease of dissection and minimization of arm clashes camera and scope, are stored in sterile fashion for later
and instrument clashes. The unique disadvantage use. The pneumoperitoneum is maintained and the
of colorectal resection, compared with prostatic
surgery for example, is the necessity to operate in
multiple, and comparatively larger, anatomical sec-
tors (e.g. 30 cm for splenic flexure and descend-
ing colon and 20 cm for the rectum versus 4–5 cm
for the retropubis). A low anterior resection with
TME requires at least two fields of view, and double
docking of the robot adds time to the procedure.
There are few advantages to robotic splenic flexure
mobilization compared with standard laparoscopic
techniques, since the space is less confined and the
surgery often requires relatively large retraction
movements crossing the surgical field. As a result,
a hybrid procedure is often preferred. This elimi-
nates the compromised position of the robot posi-
tioned by the left leg and allows the more optimal
between-the-legs docking position.
The set-up involves manoeuvring the patient-
side cart into position between the patient’s legs.
The central hub, trolley and camera arm of the ro-
bot should all be in line with the patient’s midline.
This enables the ‘sweet spot’ of the camera arm to
be found with ease and without the camera arm
getting in the way of the other instrument arms. Figure 10.5. Patient-side cart with operating arms.

HEBK001-C10_p154-170.indd 165 11/02/13 3:58 PM

 166  Robotic total mesorectal excision
Figure 10.6. Patient-side cart set up and
draped.
ports remain in place. The robotic arms are positioned
carefully under clutch control to the proximity of the
robotic ports. Each is then carefully manoeuvred and
fixed to its respective ports using their clasp attach-
ments. The assistant is then responsible for insertion
of the camera and instruments under the careful in-
struction of the surgeon now sitting at the console.
The camera is introduced first to allow for safe intro-
duction of the other robotic instruments. Although
in most cases the 08 scope is suitable for visualization,
when difficulty is encountered the 308 scope can be
used with good effect. The angled view is fixed either
‘down’ or ‘up’ for the robotic surgeon, however, who
does not have the advantage afforded the laparoscop-
ic surgeon of being able to rotate the lens of the 308
scope to view the surgical field from varying angles
while still maintaining the horizon. Each arm is fitted
in turn with an appropriate robotic instrument. The
primary arm usually holds the scissors or hook dis-
sector with monopolar diathermy attachment. The
secondary arm usually holds the Cadiere or Maryland
bipolar diathermy graspers. The third arm holds a fur-
ther grasper of the surgeon’s choice; a longer grasper
that doubles as a retractor is a useful instrument for
this arm. The assistant can lift the rectum out of the
pelvis using another laparoscopic grasper holding the
nylon tape as required. Thus, three-point traction can
be achieved, facilitating precise dissection in the cor-
rect plane in a confined space. This dissection is under
the continuous control of the operating surgeon at
the console. The assistant must be continuously alert
to the risk of robotic arm clashing and communicate
regularly with the surgeon. The assistant must also
be ready to improve vision by aspiration of the dia-
HEBK001-C10_p154-170.indd 166
thermy plume and provide tonsil and mastoid swabs
as necessary. The assistant makes a valuable contribu-
tion throughout the procedure in helping to provide
the essential traction and counter-traction to progress
with the dissection; this can usually be performed
with the suction and irrigation device. It is important
to remember that each instrument attached to a robot
arm has a fixed limited number of uses, and therefore
careful instrument choice can limit wastage and un-
necessary expense.
Pelvic Dissection
Sharp dissection using a hook or scissors attached
to monopolar diathermy is preferred by the au-
thors. The harmonic scalpel can be used, but there
is no hinge mechanism on the wrist of this instru-
ment. The bloodless mesorectal plane between the
mesorectum and parietal presacral pelvic fascia is
demonstrated easily due to the enhanced view and
by gentle anterior traction using a tonsil swab held
by a grasping instrument. The swab provides a
blunt broad compression of the posterior mesorec-
tum, minimizing the risk of fascial breach. It also
absorbs small amounts of blood and tissue fluid.
The dissection continues as far as the pelvic floor
behind and down the right side of the mesorec-
tum. It is essential for the surgeon to remember
that the sacral concavity arcs forwards as dissection
progresses, but this is well demonstrated with the
three-dimensional view offered by the robot. Extra
care must be taken not to breach the parietal pelvic
fascia; this is particularly important in the midline
11/02/13 3:58 PM

posteriorly, where the presacral veins can be dam-
aged, leading to haemorrhage that can be difficult
to control. Lateral dissection should be performed
predominantly from the right side; it is here that
the hinged robotic instruments offer a significant
advantage over standard laparoscopy. The perito-
neum is opened laterally, taking care not to inad-
vertently damage the inferior hypogastric nerve or
ureter. The posterolateral dissection is taken down
to a comfortable level, where progress starts to be-
come a little more difficult; at this stage, the ante-
rior dissection is started. The peritoneum is divided
anterior to and above the reflection. The anterior
dissection continues behind the seminal vesicles in
male patients, at which point Denonvilliers’ fascia
is reached. Denonvilliers’ fascia may exist in one or
two layers, the anterior layer behind the prostate
and the posterior layer in front of the anterior me-
sorectum. When two layers are present, they fuse
at the lower level of the prostate. At this point, the
fascia is divided to enter the plane in front of the
mesorectum. At the lateral corners of Denonvilliers’
fascia, the surgeon needs to be aware of the close
proximity of the neurovascular bundles, as these are
easily damaged at this point.
In female patients, the dissection continues down
the rectovaginal septum to the pelvic floor. The me-
sorectum is often very thin and easily breached at
this level. If dealing with an advanced anterior T3
or T4 tumour in the lower rectum, it is often neces-
sary to remove some of the posterior vaginal wall en
bloc with the specimen. An advanced upper rectal
tumour may require an en-bloc hysterectomy.
The anterior dissection is perhaps the most chal-
lenging part of the operation and may require ante-
rior retraction of the prostate to allow the dissection
to proceed to the pelvic floor under direct vision. The
mesorectal plane guides the surgeon along the pel-
vic floor to the rectal tube, which is encountered as it
passes through the pelvic floor; at this point, the dis-
section can continue into the intersphincteric plane if
required. The surgeon switches from anterior to pos-
terior to lateral as dictated by view and ease of access.
Laterally the retraction and three-dimensional view
aids the identification and preservation of the inferior
hypogastric plexus and nervi erigentes. A branch of
the inferior hypogastric nerve passes medially to the
rectum (previously known as the lateral ligament); this
nerve is variable in thickness and will need to be divid-
ed. Occasionally the nerve is accompanied by the mid-
HEBK001-C10_p154-170.indd 167
THE DA VINCI SURGICAL SYSTEM  167
dle rectal vessels, but these are by no means consistent
and are generally small and insignificant. If progress is
not being made in one area, it is important to move to
another. It is usually possible to dissect the left side of
the mesorectum from the right side of the patient. The
mesorectal dissection is started on the right and pos-
terolaterally to the left pelvic side-wall from the right
side of the patient; when coming over to the other side
of the rectum, all that remains is the division of the
peritoneum and to complete the TME. Finally, any
lower parts of the mesorectum are dissected off the
pelvic floor to reveal a clean rectal tube. The muscle
tube can then be divided at the pelvic floor.
Rectal Transection
A further nylon tape is tied around the rectal tube, tak-
ing care that it is tightened well below the lower border
of the tumour. The authors favour a distal rectal wash-
out with a cytocidal solution of iodine and water. At
this point, there are two choices. The rectum can be di-
vided with the robotic cutting instrument, followed by
the insertion of a purse-string suture using the robotic
needle driver;26 this may facilitate transanal extraction
of the specimen.27 Alternatively, if there is space for a
linear laparoscopic stapler, this can be inserted to di-
vide in the standard laparoscopic fashion. The instru-
ment cart can then be undocked after careful removal
of the robotic instruments and camera. An articulated
45-mm linear stapler cutter is then inserted via the 12-
or 15-mm (right iliac fossa) port. The distal nylon tape
is used to position the rectal tube in the jaws of the sta-
pler. Once precise positioning has been achieved, the
stapler is closed and then fired after 20 s of tissue com-
pression. The stapler is withdrawn and the nylon tape
is grasped with a ratcheted toothed grasper so that the
specimen can be easily found for extraction.
There are often difficulties getting a laparoscopic
stapler into a tight male pelvis, and it is vital not
to compromise the distal resection margin because
of inadequate instrumentation. Currently the tech-
nology is not available to provide the huge forces
necessary to generate compression and closure of
the device around an acute angle without a large
joint between the stapler head and the driving
mechanism. In these circumstances, it is better to
enlarge the Pfannenstiel incision and apply an al-
ternative narrow stapling device manually, as com-
monly used in open surgery. These staplers can be
11/02/13 3:58 PM
 168  Robotic total mesorectal excision
manipulated laparoscopically providing a seal is
established to prevent leakage of the CO2 pneu-
moperitoneum. Alternatively, the rectal muscle tube
can be divided distal to the nylon tape using the da
Vinci scissors; a purse-string suture can then be in-
serted using the da Vinci needle drivers, avoiding
the need for a linear stapler. Other options include
a sutured anastomosis performed either robotically
or with a peranal approach.
Specimen Withdrawal
A 5- to 7-cm suprapubic transverse incision is made
and a self-retracting dual ring-reinforced wound pro-
tector is used to facilitate specimen extraction. When
the mesorectum is not too bulky, the specimen may
be removed through the anal canal. The left colon is
divided at a point of convenience; there should be
a good colonic blood supply based on the marginal
artery, and sufficient length to reach the pelvic floor
without tension. Some surgeons may also favour the
fashioning of a colo-pouch. A circular stapler anvil
is inserted in the proximal colon and secured with a
purse-string suture. The colon is then returned to the
abdomen and the wound protector loosened by un-
ravelling the ring reinforcer to allow torsional closure.
This is retightened using the ring reinforcer over a
swab wrapped around the closed core. Pneumoperi-
toneum can then be re-established and an end-to-end,
end-to-side or end-to-pouch anastomosis fashioned
with the circular stapling device. The anastomosis can
be tested for air leaks, but this is usually unnecessary
as it is the authors’ routine practice to defunction all
TME coloanal/low colorectal anastomoses with a loop
ileostomy. It is our practice to carefully inspect the
doughnuts and examine the anastomosis digitally to
exclude obvious flaws.
Advantages and
disadvantages of robotic
colorectal surgery
Technical Advantages
Laparoscopic colorectal surgery is technically very
demanding and the learning curve is often long.
There is considerable restriction of movement with
standard laparoscopic instruments, with a maxi-
HEBK001-C10_p154-170.indd 168
mum of four degrees of freedom. Movements are
compromised somewhat by dependence upon the
fulcrum effect of the instruments having to pass via
ports through the abdominal wall.
The intuitive and articulated instrument move-
ments of the robot have seven degrees of freedom,
which are particularly helpful in the confined
space of the pelvis. The ports are simply a means
of access rather than an integral part of instrument
movement, as with standard laparoscopy. The ro-
bot eliminates tremor and scales down movements
made at the surgeon console, enhancing the accu-
racy of dissection.
The image of the operative field provided by high-
definition camera systems in laparoscopic surgery is
now excellent. Depth of field has to be interpreted by
the surgeon and may adversely affect performance.
The high-definition three-dimensional view provided
by the robotic optics is vastly superior to the high-def-
inition two-dimensional views produced by standard
laparoscopic cameras and display monitors. The cam-
era is held perfectly still, avoiding the risk of assistant
fatigue and reducing disorientation of the operating
surgeon. These advantages allow for more precise,
meticulous, sharp dissection of clearly identified tissue
planes, resulting in less blood loss and reduced surgi-
cal trauma. The enhanced view, intuitive instrument
movements and improved dissection quality are likely
to steepen, and therefore shorten, the learning curve
for minimally invasive TME and reduce the chance
of the need to convert to a standard open procedure.
Robotic TME may demonstrate improvements in on-
cological circumferential resection margins and pelvic
nerve preservation. It is important to emphasize, how-
ever, that this is purely conjecture until the results of
clinical trials such as the Robotic versus Laparoscopic
Resection for Rectal Cancer (ROLARR) trial, designed
to specifically investigate robotic TME compared with
laparoscopic TME, become available.
Disadvantages
One of the main disadvantages is the complete lack
of tactile feedback from the instruments. This can
potentially lead to tissue damage both in and out of
the field of view. A second drawback is the time-con-
suming procedure of the docking and undocking of
the robotic cart from the patient. If significant bleed-
ing occurs, robotic instruments cannot be changed
11/02/13 3:58 PM

quickly to deal with the problem, and the undocking
process may lead to greater blood loss before control
is achieved either laparoscopically or by open surgery.
Technological advances are in progress to create
hinged harmonic/ultrasonic energy devices and ro-
botically controlled suction devices, and the latter
are now available on the Si model. Suction can eas-
ily be added via the assistant port, however, and also
makes an excellent additional retractor to provide
counter traction.
Another disadvantage is the duration of surgery.
This applies to the set-up (docking) and the proce-
dure itself. Operating times will reduce with pro-
gression up the learning curve, but until mastery is
achieved they will always be longer than with stand-
ard laparoscopic surgery or open surgery. This has
implications for list planning, service provision and
training of juniors in the future.
A current main issue is cost, as the da Vinci sys-
tem is expensive. This applies not only to the initial
outlay for the robot but also to the cost of consuma-
bles and the annual servicing contract.
These disadvantages must be weighed against the
potential benefits of unrivalled views of the anato-
my, reduced blood loss through accurate dissection
of the tissue planes, and potentially improved nerve
preservation and quality of the TME specimen.
THE FUTURE
It is likely that robotic technology will improve with
time and become more cost-effective, smaller and ef-
ficient. There is enormous potential to improve the
quality of mesorectal dissection, and we believe this
is another step of progress in the surgical treatment
of rectal cancer.28 Cross-stapling the low rectum in a
narrow pelvis remains a challenge with the minimal
access staplers currently available, but robotic purse-
string suturing may help overcome some of these
difficulties in the short term. There are numerous
case series and several comparative studies demon-
strating equivalence or improvements in oncological
and functional outcome measures.
Robotic rectal cancer surgery is currently being
evaluated through international collaboration in a
worldwide multicentre randomized controlled trial of
robotic versus laparoscopic TME (the ROLARR trial),
whose main outcome measures are rates of conversion
to open surgery. Secondary measures are quality of re-
HEBK001-C10_p154-170.indd 169
References  169
sected specimen, positivity of resection margins, local
recurrence, quality of life, pelvic nerve function and
health economics analysis.
An excellent review by Mirnezami and colleagues
confirms there is no evidence in the medical litera-
ture to demonstrate an advantage of using the da
Vinci robot for rectal cancer surgery over standard
laparoscopic surgery.28 There is no doubt that the
view of the pelvic dissection provided by the da Vinci
three-dimensional camera system is unrivalled, mak-
ing it easier to identify important anatomical struc-
tures and dissect without damage to the pelvic nerves.
The intuitive hinged instruments also provide an ad-
vantage when dissecting in the narrow confines of
the pelvis. These are subjective rather than objective
observations, and translating them into an evidence-
based advantage may prove difficult. The literature
does, however, conclude that robotic TME is at least
as good and as safe as conventional laparoscopic sur-
gery, and it is therefore important that we engage with
and develop the technology with the hope of improv-
ing the quality of rectal TME surgery in the future.
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11/02/13 3:58 PM

Local excision and transanal
endoscopic microsurgery
Wolfgang B. Gaertner and David A. Rothenberger
Introduction
The role of local excision (LE) in the treatment of
rectal cancer is ever-evolving. Over the past 125
years, its use has varied widely, depending on the
intent of therapy (curative, palliative or compro-
mised); specific treatment goals; the safety, effec-
tiveness and local availability of alternative forms of
therapy for rectal cancer; and the decision-making
process and treatment philosophy of those involved
in choosing an optimal treatment plan, includ-
ing the patient and the surgeon. At one time, LE
through a posterior approach was the most com-
mon method used to treat patients with rectal can-
cer, for both curative and palliative intent. At other
times in the twentieth century, LE was rarely used
for curative-intent treatment of rectal cancer in
normal-risk patients, who instead were treated by
standard anterior resection or abdominoperineal
excision (APE). Local excision was used primarily
for palliation or in compromise situations, such as
when a patient’s operative risks and comorbidities
made it too dangerous to undergo standard radical
resection or because the patient refused the recom-
mended anterior resection or APE.
Today, the goals for treating rectal cancer have
broadened to include securing local and distant
oncological control; minimizing treatment-related
mortality and morbidity; performing restorative
HEBK001-C11_p171-190.indd 171
11
anastomosis to achieve near-normal continence
and defecation; preserving genitourinary functions;
and promoting rapid recovery from surgery, with a
prompt return to normal activities. This broadened
list of goals has led many surgeons to question the
dogma that all normal-risk patients with a potentially
curable invasive cancer are best served by standard
radical resection (anterior resection or APE). Instead,
they suggest a policy that uses LE in the curative-
intent treatment of patients with selected stage I rectal
cancer. Although this approach is highly controver-
sial, recent data confirm that US surgeons are increas-
ingly using LE for curative-intent treatment of rectal
cancer, despite a lack of level I or II evidence that LE is
oncologically equivalent to standard radical resection.
Proponents of this practice justify their increased use
of LE because it better achieves the other goals now
considered important in treating patients with rectal
cancer and because it is unclear that overall survival
is uniformly better after radical resection for stage I
cancer compared with LE. In addition to its use as the
sole treatment modality in curative surgery for select-
ed rectal cancer, LE is now being used with adjuvant
or neoadjuvant therapies. These controversies and
the indications, techniques and outcomes following
conventional endoanal LE and transanal endoscopic
microsurgery (TEM) for selected patients with rec-
tal cancer are the subject of this chapter. The role of
LE in the treatment of benign rectal neoplasms and
08/02/13 5:37 PM
 172  Local excision and transanal endoscopic microsurgery
the potential negative consequences of LE of what is
thought to be a benign rectal neoplasm, but is found
by histopathology on the excised specimen to har-
bour a focus of invasive adenocarcinoma, are beyond
the scope of this chapter.
Historical evolution of
local excision techniques
Surgeons have devised multiple techniques of LE for
rectal cancer that can be grouped broadly by opera-
tive approach: posterior, perineal and endoanal.
Posterior Approach
Local resection via the posterior approach was the
preferred treatment for most rectal cancers in the
late 1800s, when mortality following anaesthesia and
abdominal surgery was common. The posterior trans-
sacral approach was popularized in Europe by Kraske,
who described making a posterior longitudinal inci-
sion over the distal sacrum and coccyx to the midline
raphe of the perineum with the patient in the prone
jack-knife position.1 The rectal tumour was exposed
and resected with a 1 cm margin. The rectal wall defect
was repaired and the wound closed. This became the
most common approach for rectal cancer in Europe in
the late 1800s and early 1900s.
Mason subsequently modified this posterior
approach by dividing the anal sphincters to achieve
better exposure.2 The sphincter muscles were care-
fully preserved and tagged to facilitate suture repair
in layers after excising the rectal lesion. Although
still useful for several benign conditions, both the
Kraske trans-sacral and the Mason trans-sphinc-
teric posterior approaches to local resection for
rectal cancer have now essentially been abandoned
because of associated operative morbidity (poste-
rior faecal fistulas, anal incontinence), the increased
risk of incurable local recurrences, and the develop-
ment of safer, more effective alternative techniques.
Perineal Approach
Lockhart-Mummery advocated a two-stage
approach to the local resection of rectal cancer.3
The first stage consisted of constructing a colos-
HEBK001-C11_p171-190.indd 172
tomy under regional anaesthesia. Two weeks later,
through a transperineal incision, Lockhart-Mum-
mery performed a wide local resection of the anus
with its surrounding skin, the rectum, the contents
of the ischiorectal fossas, part of the levators and as
much of the sigmoid with its mesentery and lymph
nodes as possible. In 1926, he reported a remark-
ably low (for the time) operative mortality of 8.5
per cent in 200 patients.3 The Lockhart-Mummery
technique offered the potential advantages of a
more aggressive clearance of the cancer compared
with the limited resection done with the Kraske
trans-sacral approach, but with significantly less
mortality than the 42 per cent reported in 1908 by
Miles after APE.4 It is interesting to note that Lock-
hart-Mummery had used the Miles technique but
said he ‘had abandoned it since 1913, except for the
high cancers at the rectosigmoidal junction’. For all
other cancers of the rectum, Lockhart-Mummery
preferred his transperineal approach because it ‘was
attended with a lower mortality and was applicable
to a larger proportion of cases’.
Endoanal Approach
One of the earliest descriptions of use of the endo-
anal approach to LE of rectal cancer was by von
Volkmann in 1878, a mentor to Kocher. He noted
that it was possible to treat ‘a well-circumscribed
tumour, with the removal of which requires exci-
sion of a small portion of the rectum’, providing it
was possible to close the defect in the rectum pri-
marily by suture, preferably in a transverse fashion
to avoid the complication of a stricture.
In 1977 Morson reported the St Marks Hospital,
London, experience with LE of rectal cancers using
the endoanal approach of Sir Alan Parks.5 His endo-
anal technique is the prototype of the conventional
technique used for LE worldwide. The morbidity is
markedly less than that observed after radical resec-
tion. Technical details and outcomes are described
below. Transanal endoscopic microsurgery (TEM)
was introduced by Gerhard Buess of Tubingen,
Germany, in 1984.6 This is a modification of LE
that combines the excellent visualization offered by
endoscopy with advanced-instrument technology.
The technique allows for improved endoanal access
to the mid- and upper rectum, thus increasing the
utility of LE. Visual imaging is achieved through a
08/02/13 5:37 PM

binocular stereoscope, which permits an optimum
view during the procedure, thus enhancing the sur-
geon’s ability to accurately perform full-thickness
excisions and to repair the rectal wall defect. The
greater accuracy is reported to reduce the incidence
of positive resection margin and local recurrence
rates compared with conventional endoanal LE.7
As with conventional LE, TEM causes less opera-
tive morbidity and mortality than radical resection.
Technical details and outcomes are described below.
Current techniques
of local excision
Surgeons continue to evolve techniques for LE.
Today, the posterior approaches have essentially
been abandoned for treatment of rectal cancer,
while the endoanal LE and TEM approaches have
increased in popularity. Both endoanal LE and TEM
are increasingly used in conjunction with chemo-
radiation in an attempt to improve the outcomes
achieved by these surgical techniques when used as
sole therapy for select rectal cancer. Zerz and col-
leagues described a new combined approach, the
endoscopic posterior mesorectal resection (EPMR),
designed to allow sampling of the mesorectal nodes
while maintaining the advantages of low morbid-
ity and negligible mortality of LE.7 More recently,
Atallah and colleagues described an LE technique
using a single-incision laparoscopic port.8 These
techniques are briefly described below.
Endoanal Local Excision
Endoanal LE, as described by Parks in 1968,9 is
the most popular technique of LE. The patient is
positioned depending on surgeon’s preference and
the location of the tumour. An anterior tumour is
best approached with the patient prone, whereas a
posterior tumour, if distally located, may be better
accessed with the patient in the lithotomy position.
Mid- and proximal posteriorly based lesions are
best accessed with the patient in prone jack-knife
position. A limited distal colonic bowel prepara-
tion and preoperative antibiotics are generally used.
Preoperative deep venous thrombosis prophylaxis
is recommended. The procedure may be performed
under general or regional anaesthesia. The use of a
HEBK001-C11_p171-190.indd 173
Current techniques of local excision  173
pudendal nerve block assists with sphincter relaxa-
tion and postoperative analgesia. A Lone Star (Lone
Star Medical Products, Inc., Stafford, TX, USA)
retractor is used to efface the anus and facilitate
exposure of the distal rectum. Retractors of the sur-
geon’s choice are used to dilate the anus and expose
the cancer. A fibre-optic headlight or a retractor
with a light source is needed to adequately visualize
the lesion within the rectum.
After exposure is achieved, electrocautery is
used to define a 1-cm circumferential margin
around the tumour. Traction sutures may be
placed in the normal tissue around the tumour
to facilitate better exposure and manipulation of
the lesion. Care should be taken not to trauma-
tize the lesion or place sutures into the cancer.
A full-thickness excision is performed with the
dissection extending into the surrounding mes-
orectal fat. One must avoid injury to the vagi-
na in female patients and the prostate in male
patients. Once the specimen is fully excised, it
should be orientated and pinned before sending
it to pathology. After ensuring haemostasis, the
defect is closed transversely to minimize risk of
stricture. For large defects, a sleeve anastomosis
with interrupted absorbable sutures can be used
to advance the proximal rectum over the defect.
Although it is not our practice, if the rectal open-
ing is below the peritoneal reflection, it can be
left open with no added morbidity.10 A proctos-
copy examination is performed at the end of the
procedure to ensure the rectum is widely patent.
Postoperatively, antibiotics should be stopped
within 24 h. Patients may take a normal diet on
the evening of the operation. Postoperative anal-
gesia requirements are minimal and patients may
be discharged on the day of the operation.
Most complications after endoanal LE are
minor, with rates ranging from zero to 22 per
cent.11 Bleeding, local sepsis, urinary tract infec-
tion or retention, rectovaginal fistula and pul-
monary emboli are the most common complica-
tions. Lesions located more than 10 cm from the
dentate line can be difficult to expose and excise
in one piece with an adequate margin. If radical
resection is indicated after LE, it is important to
wait at least a month for the wound to contract
and heal, otherwise the wound could dehisce
during rectal mobilization, thus potentially spill-
ing tumour cells or faeces into the operative site.
08/02/13 5:37 PM
 174  Local excision and transanal endoscopic microsurgery
Transanal Endoscopic Microsurgery
Transanal endoscopic microsurgery has gained
increasing popularity and was developed to allow
excision of more proximal lesions than those ame-
nable to endoanal LE. The operation is performed
through a 40-mm operating rectoscope (12 cm and
20 cm in length), which is insufflated with carbon
dioxide (CO2) to obtain vision of the proximal rec-
tum. Flow can be increased to a rate of 6 L/min
and intra-rectal pressure is continuously moni-
tored and maintained at 12–15 cmH2O. Specially
designed instruments are introduced through the
rectoscope’s working ports, similar to the tech-
nique used for laparoscopic surgery. Transanal
endoscopic microsurgery offers endoscopic mag-
nification and illumination that provide excellent
visualization as well as multiple instruments that
allow precise resection and secure suture closure.
This is a particular advantage in patients with a
large body habitus, for patients with a proximally
based rectal cancer, and when performing excision
of locally recurrent lesions. A limited distal colonic
bowel preparation and preoperative antibiotics are
generally used. Bowel preparation is of particular
importance if penetration into the peritoneal cav-
ity should inadvertently occur. Informed consent
should include possible laparotomy for lesions at
high risk for entering the peritoneum, specifically
anterior tumours in female patients where the loca-
tion of the anterior peritoneal reflection is unpre-
dictable and may be quite distal.
The rectoscope is inserted up to the lesion under
direct vision with manual insufflation and then
secured to the operating table. The bevel of the
scope must face down at the lesion. The binocular
eyepiece and the accessory scope are inserted. Ade-
quate pneumorectum should be obtained without
signs of an air leak. The entire lesion should be vis-
ible, although if not, one can still proceed as long as
the entire lesion can be pulled down into the opera-
tive field. Excision of the lesion follows the same
guidelines as standard endoanal LE. Partial-thick-
ness or full-thickness excisions can be performed
with this approach, depending on the location and
nature of the lesion. In general, cancers should be
removed by a full-thickness excision with a 1 cm
margin. Most of the bleeding during full-thickness
excisions occurs during the mesorectal dissection.
In addition to conventional haemostasis with elec-
HEBK001-C11_p171-190.indd 174
trocautery, one can use a variety of commercially
available products such as a harmonic scalpel that
can simplify and speed up this step of the opera-
tion. One must also remember that the rectoscope
should be repositioned several times during the dis-
section to keep the lesion in the centre of the opera-
tive field. If the peritoneum is violated, it should
be repaired promptly, but this does not mandate
immediate conversion to laparotomy. If pneumor-
ectum is adequately maintained, one can proceed
with excision. With regard to the suturing tech-
nique, sutures are started and finished with silver
shots applied to the thread with a specially designed
applicator because traditional knot-tying is very
difficult in the rectum. Endoscopic suturing devices
(e.g. Endo Stitch™) are also being used for closure
of the rectal wall defect left after the lesion has been
excised; these add significant cost to the procedure,
however. Short sutures are preferable, and bisect-
ing the wound with an interrupted suture may also
facilitate closure. Compared with endoanal LE, CO2
distention greatly facilitates closure of the wound.
Most patients are discharged home the same day or
the day following the procedure.
Essentially, any lesion, regardless of size, location
and degree of circumferential involvement, can be
removed with TEM, as long as the upper and lower
margins of the lesion can be reached and completely
visualized. After excision of lesions that involve the
entire rectal circumference, intestinal continuity
can be re-established with a hand-sewn end-to-end
anastomosis performed through the rectoscope.
Distal rectal lesions are difficult to excise with TEM
because of the difficulty obtaining and maintain-
ing pneumorectum and difficulty using the instru-
ments in the distal rectum. Whereas exposure in
laparoscopy can be facilitated by inserting addition-
al ports or to insert the scope from a different angle,
this is not possible with TEM. The instruments are
inserted and manipulated only in parallel, and the
scope is fixed in one position. Transanal endoscopic
microsurgery is thus associated with longer opera-
tive times for such distal lesions compared with tra-
ditional endoanal LE.
Disadvantages of TEM include costly equipment
and slightly longer operating times. Although TEM
was thought to have a steep learning curve, more
recent reports have suggested a short learning curve
for the procedure in surgeons with prior experience
in minimally invasive laparoscopic surgery. As with
08/02/13 5:37 PM
 Historical role and outcomes of local excision  175
endoanal LE, TEM is also a safe procedure, with a
low rate of complications. Reported complications
include entry into the peritoneal cavity, conversion to
laparotomy, bleeding, pneumoscrotum, perineal pain,
rectal stenosis, wound dehiscence, urinary dysfunc-
tion and rectovaginal fistula. Kreissler-Haag and col-
leagues assessed complications in 288 patients under-
going TEM. They reported that tumour localization
higher than 8 cm, tumour diameter of more than
2 cm, and localization of the tumour on the lateral
wall of the rectum were risk factors for surgical com-
plications, mainly bleeding.12 Although there has been
concern about anal sphincter injury from prolonged
stretch, early studies documented no lasting adverse
effect on anorectal function. Most individual TEM
case series report mild transient incontinence, which
usually resolves within weeks. Dafnis and colleagues
reported impaired continence in 18 of 48 patients
(37 per cent) at a median follow-up of 22 months.13
These patients did not report improvement in con-
tinence over time (pre- v. post-1 year assessment),
which conflicts with other studies reporting signifi-
cant improvement within weeks.14,15 Radiotherapy
may be another factor affecting functional results after
TEM, since radiation has negatively impacted func-
tion when used in conjunction with radical surgery.16
Data regarding functional outcomes after radiothera-
py plus TEM are scant and not well defined. Patients
should be aware that significant changes in continence
may occur in the early postoperative period. Potential
risk factors include pre-existing decreased continence
or sphincter defects and large lesions requiring a more
extensive resection and prolonged operating time. The
majority of patients experience a return of pre-proce-
dure continence at 6 weeks to 3 months. The long-term
effects of an irradiated rectum after TEM remain to
be defined.
Endoscopic Posterior
Mesorectal Resection
One significant disadvantage of LE or TEM is the
lack of information regarding the lymph node
status of the mesorectum. Endoscopic posterior
mesorectal resection includes TEM or endoanal
LE of selected, favourable T1 rectal cancers fol-
lowed by a minimally invasive transperineal
resection of the posterior part of the mesorectum,
including all relevant lymphatic tissue and clip-
HEBK001-C11_p171-190.indd 175
ping of the superior rectal artery (Figure 11.1).7
Its proponents claim this technique provides
complete tumour staging with minimal morbid-
ity after LE of T1 rectal cancers.
Laparoscopic Local Excision
Atallah and colleagues reported their experience
with using a single-incision laparoscopic surgery
port for access to the rectum, replacing the con-
ventional operative rectoscope and using ordinary
laparoscopic instruments to perform LE.8 The
authors found this technique to be a safe and fea-
sible alternative to TEM, providing its benefits at a
fraction of the cost (Figure 11.2).
Historical role and
outcomes of local excision
In the late eighteenth and early nineteenth century,
LE via a posterior approach to the rectum was the
most common method of treatment of rectal can-
cer. Surgeons adopted this practice because operative
mortality following anaesthesia and abdominal sur-
gery was common. Their goals were simple: to resect
the tumour and keep the patient from dying from the
operation. During the first half of the twentieth cen-
tury, mortality after elective colorectal cancer surgery
fell steadily from 41 per cent in 1916–1920 to 7 per
cent in 1946–1950.17 As anaesthesia and abdominal
surgery became safer, surgeons embraced the Miles
APE because of its superior oncological control com-
pared with that achieved by LE. Abdominoperineal
excision became the operation of choice for rectal
and rectosigmoid cancers in most centres around the
world. In the 1950s, anterior resection and colorectal
anastomosis was shown to achieve oncological out-
comes identical to APE for distal sigmoid and proxi-
mal rectal cancers without the morbidity of a perma-
nent colostomy.
By the 1970s, mortality following radical resec-
tion for rectal cancer had dropped to 5 per cent or
less in most series. A reliable circular stapler that
facilitated distal colorectal anastomosis was intro-
duced in 1978. Soon, anterior resection became the
procedure of choice for all but the most distal rec-
tal cancers, as surgeons pushed the distal limits of
sphincter-sparing proctectomy. The goals of surgery
08/02/13 5:37 PM
 176  Local excision and transanal endoscopic microsurgery

Figure 11.1. Technique of endoscopic posterior mesorectal resection. (A) Trocar positions. (B) Access to the retrorectal
space using the index finger. (C) Establishment of a sufficiently large operating space using a dissecting balloon trocar.
(D) Dissection of the mesorectum from the posterior wall of the rectum.

for rectal cancer had expanded beyond safety and
local oncological control to also include sphincter
preservation and avoidance of permanent colosto-
my. Local excision of rectal cancer seemed relegated
to use only in high-risk patients, in patients refus-
ing radical resection and for palliation. A dissent-
ing opinion came in 1977, when Morson and col-
leagues reported the St Marks experience with LE
of rectal cancers using the endoanal approach of Sir
Alan Parks.18 They reported equivalent oncological
results after LE compared with radical resection but
with significantly less morbidity and mortality.
In the 1980s, reports of high rates of local recur-
rence and major operative morbidity, including
anastomotic leak, anterior resection syndrome
and genitourinary dysfunction, after low anterior
resection and distal anastomosis caused physicians
to re-examine the preferred approach to rectal
cancer. Radiation therapists and medical oncolo-
gists argued for postoperative chemoradiation to
enhance oncological outcomes. Heald and others
held workshops to teach surgeons how to optimize
surgical technique by conducting a total mesorec-
tal excision (TME) as part of anterior resection
or APE.19 Various technical modifications to ante-
rior resection and APE are now included under the
term TME. Proponents argued that the surgeon
could achieve better oncological outcomes, increase
sphincter preservation with coloanal anastomosis,
improve anorectal function by using a colo-pouch,
and maintain genitourinary function by using a
meticulous pelvic dissection technique.
The role of LE in treatment of rectal cancer varied
widely from centre to centre in the 1980s. Some sur-
geons rarely used LE for any indication, while oth-
ers, noting the significant morbidity and less than
ideal oncological results following standard anterior
resection and APE, increasingly used LE as an alter-
native in patients marginally unfit for radical resec-
tion. At the same time, new and improved imaging
techniques, including endorectal ultrasonography
(ERUS), magnetic resonance imaging (MRI) and
computed tomography (CT), held the promise of
being able to reliably and accurately stage rectal
cancer, thus minimizing the risk that the use of LE
would undertreat a patient with rectal cancer. Our

HEBK001-C11_p171-190.indd 176 08/02/13 5:37 PM

 Current role and outcomes of local excision  177
Figure 11.2. Transanal minimally invasive surgery (TAMIS).
Single-port access is used to facilitate minimally invasive
surgery so that transanal excision of rectal lesions
can be performed. This is a novel approach that is a
hybrid between single-port laparoscopy and transanal
endoscopic microsurgery. Shown here is the SILS™ Port
in position within the anal canal (A). Insufflation of the
rectum is established with a dedicated port. Through the
remaining three cannulas, two are used for laparoscopic
instrumentation and one is used for a 5-mm camera (B).
experience with increased use of curative-intent LE
for marginally unfit patients was consistent with
Morson’s favourable report.18 As a result, we slow-
ly began using LE for curative-intent treatment in
normal-risk patients. We initially selected what we
thought were only the most favourable, small T1
cancers for LE; when results seemed reasonable, we
gradually liberalized our selection criteria and began
including selected T2 cancers. We were dismayed
when our longer-term follow-up showed high rates
of local recurrence following LE of both T1 and T2
lesions.20,21 Soon, results from other large single insti-
tutions that had similarly liberalized the use of LE
also showed higher than expected local recurrence
rates; some studies showed a decrease in overall sur-
vival following LE.22,23 Local recurrence rates ranged
HEBK001-C11_p171-190.indd 177
from zero to 28 per cent for T1 lesions and from 11
per cent to 45 per cent for T2 lesions, whereas 5-year
survival rates ranged from 74 per cent to 90 per cent
for T1 lesions and from 55 per cent to 75 per cent for
T2 lesions. The wide variation in reported outcomes
probably reflects differences in patient selection,
intent of surgery and surgical technique. We also
found that radical salvage surgery in patients with
local recurrence after LE was not always curative.24
It seemed that LE did not equal the oncological out-
comes historically achieved with standard anterior
resection or APE for similarly staged cancers. As a
result, the use of LE for curative-intent treatment of
rectal cancer was curtailed in many centres, includ-
ing our own.
Current role and outcomes
of local excision
The current role of LE for treating patients with
rectal cancer is controversial. Consensus opinion
as noted in practice guidelines and surgical text-
books is that the standard curative-intent operation
of choice for normal-risk individuals with rectal
cancer including stage I lesions is radical resection
(anterior resection or APE) performed with the
meticulous dissection and other techniques now
encompassed in TME. This is supported by data
such as those offered by Blumberg and colleagues.25
They reported that patients with stage I rectal can-
cer who undergo radical anterior resection with
sphincter-sparing anastomosis or radical abdomi-
noperineal excision of the rectum with colostomy
generally benefit from a high cure rate, with 5-year
survival rates around 90 per cent. Given this con-
sensus, the appropriate role of LE in curative treat-
ment of stage I rectal cancer would seem to be very
limited. It is thus surprising that You and collabora-
tors reported that LE had been used increasingly for
stage I rectal cancer.26
One may speculate as to why LE has increased
in use in the USA. It is possible that the increased
enrolment in national screening programmes for
colorectal cancer has led to diagnosis of a higher
proportion of early-stage rectal cancers, includ-
ing rectal cancers arising in sessile polyps, some of
which may be potentially amenable to LE. Addi-
tionally, new neoadjuvant treatment regimens may
lead to more effective down-staging of stage II and
08/02/13 5:37 PM
 178  Local excision and transanal endoscopic microsurgery
stage III rectal cancers, potentially making some
patients whose cancers demonstrate a complete or
near-complete clinical response amenable to cur-
ative-intent LE.27–31 Local excision in combination
with adjuvant or neoadjuvant chemoradiotherapy
for early-stage rectal cancer is being assessed in ran-
domized trials. Its use in compromise situations and
for palliation is more difficult to assess but is likely
increasing. With an ageing population, there may
be an increase in the number of patients for whom
local therapy is selected as a compromise treatment
rather than selecting a conventional radical treat-
ment protocol for an elderly patient with significant
operative risk factors. The extent to which any of
these possible explanations underlies the apparent
increased use of LE is unclear. Regardless, it is obvi-
ous that the current role of LE in the treatment of
rectal cancer is still being defined.
Curative-Intent Local Excision
You and colleagues used the National Cancer Data-
base to examine choice of surgical therapy over time
for 35 179 patients diagnosed with stage I rectal
cancer between 1989 and 2003.26 They found that
LE increased from 26.6 per cent to 43.7 per cent for
T1 cancers and from 5.8 per cent to 16.8 per cent
for T2 lesions. This is a remarkable trend given the
lack of level I or II evidence that LE is oncologically
appropriate for curative-intent surgery of stage I
rectal cancer. They further analysed 2124 patients
with stage I rectal cancer diagnosed between 1994
and 1996 to assess perioperative outcomes, local
recurrence and survival. Local excision was used
in 765 patients (601 with T1 cancer, 164 with T2
cancer) and standard radical resection was done in
1359 patients (493 with T1 cancer, 866 with T2 can-
cer). Patients treated by LE experienced significant-
ly lower 30-day morbidity than patients undergo-
ing standard radical resection (5.6 per cent v. 14.6
per cent). The 5-year local recurrence rate after LE
versus radical resection, however, was significantly
higher (12.5 per cent v. 6.9 per cent for T1 cancers;
22.1 per cent v. 15.1 per cent for T2 cancers). The
5-year overall survival, however, was influenced by
age and comorbidities but not by choice of surgery
in both T1 cancers (77.4 per cent after LE v. 81.7
per cent after radical resection) and T2 cancers
(67.6 per cent after LE v. 76.5 per cent after radi-
HEBK001-C11_p171-190.indd 178
cal resection). The authors concluded that there is
an increased use of LE for stage I rectal cancer, but
there are associated risks of local failure and the
benefits of LE must be balanced against such risks.
Winde and colleagues randomized 50 patients
with T1 rectal cancer to either TEM or anterior
resection.32 At a mean follow-up of 46 months, there
was no significant difference in the local recurrence
rate (4.2 per cent v. 0 per cent) or survival rate (96
per cent v. 96 per cent) between the two groups.
Lezoche and colleagues randomized patients with
T2N0 rectal cancer to TEM or laparoscopic stand-
ard radical resection with TME after neoadjuvant
chemoradiation therapy. Local recurrence (5.7 per
cent v. 2.8 per cent) and survival (94 per cent for
both groups) were not significantly different after
84 months of follow-up.33
For proponents of LE, the apparent lack of a del-
eterious effect of choice of therapy on 5-year over-
all survival was reassuring and added credence to
their opinion that LE should play a significant role
in curative-intent treatment of select rectal cancers.
Additional support for this view derives from the
observation that radical surgery does not cure all
patients with stage I disease and is associated with a
30-day postoperative mortality of 1.6–4.8 per cent,
an often prolonged recovery and major ­morbidity.34
Anastomotic leak, pelvic sepsis, perineal wound
problems, colostomy complications, and bowel,
sexual and urinary functional disturbances may
adversely affect the patient’s long-term quality
of life. By contrast, LE of rectal cancer will confer
undisputed benefits of negligible mortality, mini-
mal morbidity with rapid recovery, and reasonable
preservation of genitourinary and anal sphincter
function. In a recent update of the Cancer and
Leukemia Group B trial on local excision of distal
rectal cancer (CALGB 8984), Greenberg and col-
laborators presented data supporting the concept
that patients with selected T1 cancers treated by LE
have comparable rates of local recurrence, overall
survival and disease-free survival as historic con-
trols treated by radical resection.35 As noted in the
discussion about Greenberg and colleagues’ paper,
the use of historic controls and other design issues
make this a less than totally convincing argument
to routinely use LE for selected stage I rectal can-
cers. The critical and still unresolved controversial
issues are: does LE for selected stage I rectal can-
cers provide oncological outcomes equivalent to
08/02/13 5:37 PM
 Current role and outcomes of local excision  179
that achieved by radical resection, and if not, do the
advantages of LE outweigh the oncological disad-
vantages?
Curative-Intent Transanal
Endoscopic Microsurgery
Local recurrence after TEM has been reported
mainly in single-institution reviews with lim-
ited numbers, which makes comparisons difficult.
Recurrence rates after TEM range from zero to 13
per cent for patients with T1 tumours and from
zero to 80 per cent for patients with T2 tumours.
Bach and colleagues reported the outcomes of 424
patients with rectal cancer treated with TEM and
entered into a national database.36 A positive resec-
tion margin occurred in 11 per cent, 22 per cent and
42 per cent of patients with T1, T2 and T3 tumours,
respectively. Patients who were observed after TEM
(with or without postoperative radiation) were 15
times more likely to develop local recurrence than
those who were converted to standard radical resec-
tion (anterior resection or APE) with TME based
on unfavourable histological findings in the TEM
specimen.
We analysed our results with TEM at the Univer-
sity of Minnesota in 95 patients with rectal carci-
noma (58 T1, 26 T2, 11 T3).37 Follow-up time was
49.5 months. Local recurrence rates for 83 malig-
nant tumours were 9.8 per cent for T1 tumours,
23.5 per cent for T2 tumours and 100 per cent for
T3 tumours. Ganai and colleagues studied the out-
comes of 28 patients with malignant rectal tumours
(8 T in situ (Tis), 12 T1, 4 T2, 4 T3) who under-
went TEM.38 Margin positivity occurred in 14 per
cent of patients (4/28). Mean follow-up time was 46
months. Local recurrence occurred in 15 per cent of
patients. Depth of invasion was related to the likeli-
hood of invasive local recurrence, and lesions larger
than 4 cm had a higher rate of recurrence. Median
time to recurrence was 15 months. The authors rec-
ommended close endoscopic follow-up after TEM.
Stipa and colleagues reviewed the outcomes of
69 patients with early rectal cancer who underwent
TEM.39 The 5-year local recurrence rate was 8 per
cent for Tis tumours, 8.6 per cent for T1 tumours
and 9.5 per cent for T2 tumours. The median time
to recurrence was 10.5 months. Of 14 patients who
received preoperative chemoradiation (2 T1, 12 T2
HEBK001-C11_p171-190.indd 179
tumours), no local recurrences occurred, and only
1 patient with T2 disease had distant recurrence.
All local recurrences were managed surgically. The
5-year disease-specific survival rate was 100 per
cent for Tis tumours, 100 per cent for T1 tumours
and 70 per cent for T2 tumours.
Comparisons of Curative-Intent
Endoanal Local Excision and
Transanal Endoscopic Microsurgery
Although You and colleagues did not distinguish
traditional endoanal LE from TEM,26 there is
increasing literature comparing the two techniques.
Unfortunately, most studies are retrospective single-
institution experiences (Table 11.1). Moore and col-
leagues compared endoanal LE (n 5 89) and TEM
(n 5 82) and showed no differences in complica-
tions.5 Transanal endoscopic microsurgery was more
likely to yield clear margins and a non-fragmented
specimen. At a mean follow-up of 37 months, recur-
rence was less frequent after TEM than after tradi-
tional LE (5 per cent v. 27 per cent). At our insti-
tution, we retrospectively compared endoanal LE
(n 5 129) and TEM (n 5 42). We evaluated quality
of resection, local recurrence and survival rates in
patients with stage I rectal cancer.40 Although surgi-
cal margins were less often positive with TEM, the
estimated 5-year disease-free survival rate was simi-
lar between the groups (TEM 84 per cent v. endo-
anal LE 76 per cent). We found that tumour distance
from the anal verge, resection margin status, T stage
and use of adjuvant therapy, but not surgical tech-
nique (LE or TEM), were independent predictors of
local recurrence and disease-free survival.
Curative-Intent Endoscopic Posterior
Mesorectal Resection
Two years after the description of EPMR by Zerz
and colleagues, Tarantino and colleagues reported
their experience with this promising technique.44
They performed EPMR 6 weeks after LE in 18 con-
secutive patients with T1 tumours (13 endoanal LE,
5 TEM) and compared their results with historical
controls that underwent low anterior resection with
TME. Both groups included patients with low- and
high-risk histology with no significant differences.
08/02/13 5:37 PM
 180  Local excision and transanal endoscopic microsurgery

The median number of lymph nodes resected was

survival (%)
7 for EPMR and 11 for low anterior resection. Of

Overall
importance, an anatomical study found a mean of

NS
93
96

94
77
8.4 lymph nodes in the mesorectum.45 At a median
follow-up of 23 months, one patient developed dis-

recurrence
tant metastases but there was no evidence of local
recurrence in either group. They concluded that
Local

(%) although the lymph node harvesting of EPMR was

9.4

2.8
0

0
not comparable to that of TME, EPMR allowed for
TME

adequate lymph node staging and showed equiva-

Mortality

lent outcomes for T1 tumours. This technique may

Table 11.1. Studies comparing transanal endoscopic microsurgery (TEM) versus total mesorectal excision (TME) for early rectal carcinoma.

(%)

3.7
prove useful to accurately identify otherwise occult
0

0
4
metastatic mesorectal nodes and thus facilitate
appropriate selection of curative-intent therapy for
Complications

apparently-early stage rectal adenocarcinoma.

(%)
48

56
17
64

Curative-Intent Local Excision as Part

of Multimodality Therapy
22
83
18
35
75
n
survival
Overall

Dissatisfaction with oncological control offered by

100
(%)

NR

LE as the sole therapy for rectal cancer led some

95

94
75

centres to use postoperative radiation with or with-

out sensitizing chemotherapy. Advocates argued
recurrence

that by doing LE first, the exact depth of tumour

Local

invasion and histological features of the primary

19.5
(%)
4.1

5.7
10

24

tumour could be assessed properly. Some centres

chose to use adjuvant chemoradiation therapy for
Mortality
TEM

T1 cancers with unfavourable features or for T2

(%)

cancers. The hypothesis was that adjuvant therapy

0

0
0
0

following curative-intent LE would treat occult

Complications

local spread or occult lymph node metastases and

thus improve oncological outcomes without sub-
jecting the patient to the complications of radical
(%)
4.1

7.6

surgery. As neoadjuvant chemoradiation therapy

14
5

has been more accepted for use in advanced-stage

52
22
20
35
80

rectal cancers before radical surgery, its use was

n

suggested for treatment of small early-stage rec-

Follow-up

tal cancers in combination with LE. Its role in this

(months)
31–35

21–43

setting is now the subject of an ongoing national

84
64

trial in the USA. Advocates argue that one can use

local tumour response to estimate the likelihood
T stage

of persistent nodal disease. Whether this is true is

debated.
1
2
1
2
1

NR, not reported.

Adjuvant therapy
43
Lezoche et al.33
De Graaf et al.
42

A multi-institutional phase II prospective trial eval-

Langer et al.
41

uating adjuvant chemoradiation therapy after LE

Lee et al.
Study

divided patients into three groups based on the final

histopathological findings.46 Group 1 patients had T1

HEBK001-C11_p171-190.indd 180 08/02/13 5:37 PM

 Current role and outcomes of local excision  181
Table 11.2. Studies assessing chemoradiotherapy before local excision of early rectal carcinoma.
Pathological complete
Study T stage response (%)
T1 T2
Kim et al.27 26 73 4 92
Bonnen et al. 48
– 26 54
Lezoche et al.28,29 35 – 32
Callender et al. 49
– 47 49
Yeo et al.50 – 11 73
Garcia-Aguilar et al.51 77 – 43
NR, not reported.
lesions with favourable histology and negative margins
and were observed without adjuvant therapy. Group 2
patients had T1 tumours with unfavourable histology
or lesions greater than or equal to T2 and received the
standard long-course dose of chemoradiation therapy.
Group 3 patients were the same as group 2, except the
resection margins were positive for malignancy, and
therefore they received a higher dose of chemoradia-
tion therapy. After a median follow-up of 6.1 years,
local-regional recurrences developed in 16 per cent of
the patients (8/65). The risk of recurrence correlated
with T stage (T1, 4 per cent; T2, 8 per cent; T3, 23 per
cent) and the degree of involvement of the resection
margin. For the two groups treated with chemoradia-
tion therapy, the 5-year actuarial freedom from pelvic
relapse was 86 per cent, comparing favourably with
historical controls treated with TME and suggesting a
beneficial effect of chemoradiation therapy.
The Cancer and Leukemia Group B conduct-
ed a similar prospective multi-institutional trial
comparing the outcomes of 59 patients with T1
tumours treated with LE alone and 51 patients
with T2 lesions treated with LE and postoperative
chemoradiation therapy.35 At a median follow-up
of 7.1 years, the local recurrence rates were 8 per
cent for T1 lesions and 18 per cent for T2 cancers.
The 10-year actuarial overall survival and disease-
free survival rates were 84 per cent and 75 per cent
for T1 cancers and 66 per cent and 64 per cent for
T2 cancers, respectively.
Neoadjuvant therapy
Although most studies evaluating neoadjuvant
therapy have small numbers and are retrospective
in nature, they do suggest that preoperative chemo-
radiation therapy can indeed down-stage tumours
subjected to subsequent LE and also lower recur-
HEBK001-C11_p171-190.indd 181
Recurrence, local/
distant (%) Survival (%)
11 86
9 94
21 79
18 89
NR NR
rence rates compared with LE alone (Table 11.2).
One of the first reports on preoperative radio-
therapy was by Mohiuddin and colleagues.47 Thirty
patients with T3 tumours were treated with preop-
erative radiotherapy followed by LE. They reported
a pathological complete response in 11 patients (36
per cent), a 5-year recurrence rate of 10 per cent
and a survival rate of 83 per cent.
Bonnen and colleagues compared the outcomes of
LE and radical resection with TME after preoperative
chemoradiation therapy.48 Of 26 patients, 54 per cent
(n 5 11) had a pathological complete response and 35
per cent had microscopic residual disease. The 5-year
local recurrence rate in the patients undergoing LE
was 6 per cent and overall survival was 86 per cent,
compared with 8 per cent and 81 per cent, respective-
ly, for the TME group. The results of this study were
updated with a median follow-up of 63 months.49
Ten-year actuarial local recurrence was not signifi-
cantly different between the LE and TME groups (10.6
per cent v. 7.6 per cent), and no significant difference
in survival was found between the groups. Kim and
collaborators at the Lee Moffitt Cancer Center retro-
spectively reviewed the outcomes of 26 patients who
received neoadjuvant therapy followed by LE for T2
and T3 rectal cancers.27 Pretreatment ERUS staging
included 5 T2N0, 13 T3N0, 7 T3N1 and 1 not done.
Pathological complete and partial responses were
achieved in 9 of 26 (35 per cent) and 17 of 26 (65 per
cent) patients, respectively. At a mean follow-up of
24 months, only one tumour with partial response,
in a patient who refused APE, had recurred. None
of the tumours with complete pathological response
recurred. Nair and colleagues reported a recurrence
rate of 16 per cent after neoadjuvant chemoradiation
therapy and endoanal LE for T2 and T3 rectal can-
cers.52 The overall 5-year survival was 84 per cent in
08/02/13 5:37 PM
 182  Local excision and transanal endoscopic microsurgery
node-negative patients. The results of these studies
contrast with other series that have shown higher rates
of lymph node positivity after TME as well as lower
responses to chemoradiation therapy. These differenc-
es probably reflect selection bias, with patients having
more favourable tumours likely undergoing LE.
In a prospective randomized trial, Lezoche and col-
leagues compared TEM and TME after neoadjuvant
chemoradiation therapy in patients with T2N0 rectal
cancer.28,29 The overall pathological complete response
rate was approximately 35 per cent in both groups. In
an update of this trial with a median follow-up of 84
months, 2 of 35 patients (5.7 per cent) had local recur-
rence in the TEM group and only 1 of 35 patients (2.8
per cent) had recurrence in the TME group. Disease-
free survival after 84 months of median follow-up was
similar (94 per cent) in both groups.
Overall, there seems to be a trend towards lower
recurrence rates and higher disease-free survival
with neoadjuvant or adjuvant therapy compared
with LE alone. This may be more beneficial in high-
risk histology tumours and T2 or T3 tumours. For
patients with a pathological complete response
documented on the surgical specimen, the reported
rate of positive nodes in the mesorectum ranges
from zero to 12 per cent. Therefore, LE may not
guarantee a curative resection, even in patients with
ypT0 tumours after chemoradiotherapy and LE.
What needs to be defined is the risk of nodal metas-
tasis in patients with clinically N0 tumours who
become ypT0 after chemoradiation.
Another question that remains unanswered is
the efficacy of neoadjuvant therapy in T2N0 rectal
adenocarcinoma followed by LE. This is currently
being addressed by the American College of Surgeons
Oncology Group trial Z6041, a multicentre phase II
clinical trial using neoadjuvant chemoradiation ther-
apy followed by LE in patients with ultrasound-staged
T2N0 rectal cancer. Preliminary results presented as
an abstract reported a 98 per cent resection rate with
negative margins.51 Down-staging occurred in 49 of
77 patients (64 per cent), with a pathological complete
response rate of 43 per cent.
Local Excision for Compromise
and Palliation
Local excision has long been used for patients
judged to have comorbidities that put them at high
HEBK001-C11_p171-190.indd 182
operative risk for radical surgery. For the most part,
even patients with major illnesses can tolerate LE,
providing the rectal cancer does not exceed the
technical limits of the operation. Similarly, when
patients refuse a recommended radical surgery, usu-
ally because of the refusal to accept a permanent
colostomy, the surgeon may consider LE as an alter-
native therapy. This can pose an ethical dilemma for
the surgeon, since patients often cannot compre-
hend that use of LE, even for relatively early-stage
rectal cancer as a compromise indication, may result
in incurable painful local recurrence that often
requires further palliative treatment. Local excision
for palliation is used selectively, but the cancer can-
not exceed the technical limits of the operation.
Patient and cancer selection
for local excision
Criteria for selecting patients with rectal cancer
who would benefit from LE vary depending on the
intent of therapy, the patient’s desires, the treatment
philosophy and techniques offered by the treating
physicians, and, most importantly, the stage and
characteristics of the primary cancer. That LE can
cure some rectal cancers is not in dispute, but the
question is whether we have the ability to accurately
distinguish patients whose rectal cancer is almost
certain to be cured by LE from patients whose rectal
cancer is unlikely to be cured by LE. There are risk
factors that can be identified during pretreatment
evaluation that are contraindications to curative
intent LE, but there is no widely accepted evidence-
based list of criteria that surgeons can use to select
rectal cancers for curative intent LE. Clinical, path-
ological and imaging assessments of the primary
rectal cancer are essential to determine whether LE
is even to be considered as a viable option for cura-
tive intent treatment.
Assessing the Primary Rectal Cancer
for Local Excision
Not all rectal cancers can or should be resected by
LE. The surgeon must assess the primary rectal
cancer to determine whether LE is technically pos-
sible and whether doing so is likely to achieve the
therapeutic goals. It is important that the surgeon
08/02/13 5:37 PM
 Patient and cancer selection for local excision  183
recognizes when not to attempt LE even for pal-
liation. Most surgeons agree that LE should be con-
sidered only if the cancer is in an accessible part of
the rectum and small enough to be totally excised
in one piece with a 1 cm margin of normal rectum.
Additionally, most surgeons would agree that ideally
the cancer is confined to the rectal wall (T1 or T2).
Sometimes exceptions are made in cases of com-
promised intent therapy or palliative intent therapy.
Clinical, pathological and imaging assessments are
key elements to achieving pretreatment staging of
the rectal primary tumour.
Tumour size, location and morphology
Careful digital rectal examination with proctos-
igmoidoscopy to palpate and visualize the rectal
cancer can determine the lesion’s size, precise level
and location in relation to the anal sphincters and
other structures, and the presence of gross features
associated with a poor prognosis. Although tumour
size is not a reliable predictor of depth of invasion
or nodal metastasis, patients with tumours larger
than 3–4 cm in diameter or involving more than
40 per cent of the circumference of the rectum are
poor candidates for traditional endoanal LE, sim-
ply because adequate exposure is difficult to obtain
with conventional retractors.53 Proponents of TEM
report that this approach provides better exposure
and visualization, such that the size of the lesion is
less of an issue than with endoanal LE. Although
tumour distance from the anal verge does not have
independent prognostic value when stratified by
tumour stage,54,55 it is an important consideration
if LE is being considered. Traditional endoanal LE
provides reliable access to distal and most mid-rec-
tal lesions, while TEM provides access to mid- and
proximal lesions but is difficult to use for the most
distal cancers. An additional consideration for the
surgeon is whether the location of the cancer allows
full-thickness excision of the rectal wall without
entering the peritoneal cavity. Distal and posterior-
ly based mid-rectal cancers are extraperitoneal and
generally can be excised safely without much risk
of peritonitis if the rectal wall defect fails to heal.
Proximal lesions and anteriorly based mid-rectal
cancers are likely to be intraperitoneal, and their
full-thickness excision may increase the risk of peri-
tonitis if a leak occurs and risk other organ injury
to adjacent structures such as the vagina or pros-
tate. Transanal endoscopic microsurgery reputedly
HEBK001-C11_p171-190.indd 183
offers the ability to more securely suture repair the
rectal wall defect for proximal lesions than is possi-
ble with endoanal LE. Although tumour morphol-
ogy does not have independent prognostic value
when stratified by tumour stage,54,55 it is often used
as a surrogate for depth of invasion, since most
ulcerated lesions are T3 or T4. Thus, many surgeons
avoid LE for ulcerated cancers.
Histopathology
Biopsy of the primary lesion may reveal microscopic
features associated with lymph node metastases,
local recurrences, and a poor prognosis such as lym-
phovascular and perineural invasion or mucinous,
signet ring or poorly differentiated histology. If these
are present on pretreatment biopsy, LE is generally
contraindicated. The rates of local recurrence and
lymph node involvement in T1, grade 1, well-differ-
entiated tumours are 0–3 per cent, whereas T1, grade
3 poorly differentiated tumours have 12 per cent
nodal involvement and a 10–63 per cent chance of
local recurrence.12,56
Ulcerated mucinous cancers and lesions with evi-
dence of perineural and lymphovascular invasion
are associated with local recurrence rates as high
as 25 per cent.12,56 Chemoradiotherapy regimens
are less effective in tumours with undifferentiated
histology and lymphovascular invasion.57 Tumour
budding, defined as isolated cancer cells or nests
of cancer cells in normal tissue at the edge of the
main tumour, has been associated with lymph node
metastases in up to 25 per cent of patients with T1
cancers and has been identified as a predictor of
worse survival independent of disease stage.58,59 The
literature is unclear as to how often histopathol-
ogy of the final specimen obtained by LE results in
identification of one of these unfavourable features
not noted on pretreatment biopsy.
Depth of invasion, nodal metastases
and local spread
Nodal metastases, direct intrapelvic spread and mes-
orectal spread are contraindications for curative intent
LE in average-risk patients and relative contraindica-
tions for LE in other settings (palliation or compro-
mise). All of the risk factors discussed above are sur-
rogate markers for nodal metastases or local spread,
but the most important correlate is depth of invasion
of the primary cancer (Table 11.3). At a minimum,
tumours that are considered for curative intent LE
08/02/13 5:37 PM
 184  Local excision and transanal endoscopic microsurgery
Table 11.3. Morphologic features of favourable and
unfavourable T1 rectal cancers.
Favourable/ Unfavourable/
low risk high risk
Differentiation Well differentiated Poorly differentiated
(G1–G2) (G3)
Submucosal 1 2–3
  invasion
Lymphovascular No Yes
  invasion
Size ,3 cm .3 cm
Wall circumference ,40% .40%
should be localized to the rectal wall (T1 and T2).
Nodal involvement occurs in 0–12 per cent of T1
tumours and 12–28 per cent of T2 tumours.56,60 Kudo
first introduced the concept of dividing T1 cancers
into three levels based on the extent of submucosal
invasion, varying from the superficial third to the
middle third to the deepest third (sm1, sm2, sm3).61
Several studies have demonstrated an association of
deeper submucosal invasion with increasing risk of
lymph node metastases in 0–3 per cent for sm1 lesions
to 20–23 per cent for sm3 lesions,53,62 with increased
rates of local recurrence for sm3 lesions.63 Additional-
ly, gender may be a predictive marker for lymph node
metastasis in early rectal cancer. Kobayashi and col-
leagues showed that 1 per cent of male patients with
well-differentiated T1 tumours of the lower rectum
had lymph node metastasis, compared with 30 per
cent in female patients with histological types other
than well-differentiated adenocarcinoma, even when
the tumour did not invade the muscularis propria.64
The authors suggested that these patients should not
undergo LE.
Serum carcinoembryonic antigen may be useful
as a baseline study. A CEA level that is elevated and
drops to normal after resection is reassuring. Per-
sistence of an elevated CEA level after treatment or
a rising CEA level should alert the surgeon to the
possible presence of metastatic disease or incom-
plete resection. Perez and colleagues showed that a
CEA level below 5 ng/mL after chemoradiotherapy
is a favourable prognostic factor for rectal cancer
and is associated with increased rates of earlier
disease staging and complete tumour regression.65
Conversely, an elevated pre-chemoradiotherapy
serum CEA level (. 5 ng/mL) is associated with
poor tumour response to chemoradiotherapy.66
HEBK001-C11_p171-190.indd 184
Imaging studies used to stage rectal cancer
include CT, MRI and ERUS. New-generation CT
scanning and surface-coil MRI are able to detect
tumour invasion outside the rectal wall,67 but they
cannot reliably distinguish between a T1 and a T2
lesion or between a benign lesion and a T1 lesion.
Endorectal ultrasonography and endorectal coil
or 3-tesla MRI can provide this level of detail, and
either of these studies should be performed in
the evaluation of any patient considered for LE.
Although MRI is more expensive and less available
than ERUS, it does not suffer from the interobserv-
er variation that plagues endosonography, and it is
the optimal way to assess mesorectal invasion and
determine whether the circumferential radial mar-
gin is involved, threatened or free of tumour.
In a meta-analysis including data from 90 publi-
cations, Bipat and colleagues found the sensitivity of
ERUS and MRI for tumour invasion outside the rec-
tal wall was as high as 90% and 82%, respectively.68
The sensitivity for lymph node involvement was sig-
nificantly lower, however, at 67 per cent and 66 per
cent, respectively. In a systematic review of 53 studies
including 2915 patients, the accuracy of ERUS was 87
per cent for T stage and 74 per cent for lymph node
involvement;69 for MRI with endorectal coil, the cor-
responding numbers were 84 per cent and 82 per cent.
Data have shown that three-dimensional reconstruc-
tion increases the accuracy of ERUS in assessing the
depth of rectal wall and submucosal invasion and may
help in selecting patients for local excision.70
Because the gold standard for assessing the accu-
racy of any imaging study should be the final non-
irradiated pathology specimen, many studies are
biased by selective inclusion and exclusion criteria.
Patients with advanced disease who undergo neoad-
juvant therapy are generally excluded, and patients
with clearly localized lesions who are offered LE are
similarly often excluded. Thus, the patients left for
evaluation are those with more equivocal findings
on imaging studies. This selection bias has likely led
to an underestimation of the accuracy of ERUS and
MRI.
Assessing the patient with
rectal cancer
The goals of the pretreatment evaluation are to
identify conditions and issues that will affect the
08/02/13 5:37 PM

choice of therapy. In addition to carefully staging
the primary rectal cancer as noted above, distant
metastases, especially to the liver and lungs, and
synchronous gastrointestinal or colonic abnormali-
ties, diseases or prior surgery that may complicate
the treatment plan must be assessed. Pre-existing
comorbidities, baseline bowel function includ-
ing continence and defecation and operative risks
can largely be defined by a thorough history and
physical examination, with additional laboratory or
other testing as needed. The surgeon must under-
stand the patient’s desired outcome and assess their
psychosocial state, decision-making capability, and
availability of family or others for support during
the stressful periods likely to arise as the rectal can-
cer is treated. A complete review of the pretreat-
ment assessment is beyond the scope of this chapter
but is available elsewhere.71
Optimal therapy selection:
role of a multidisciplinary
team
Despite new and improved imaging, pretreatment
staging of rectal cancer has inherent significant
inaccuracies, especially in detecting lymph node
metastases and making subtle distinctions between
T stages. Thus, what is thought to be a stage I rectal
cancer may actually be a stage II or stage III rectal
cancer. This means that the decision to use endo-
anal LE or TEM, techniques characterized by ‘total
mesorectal neglect’, for an alleged stage I rectal can-
cer rather than performing a standard radical resec-
tion with TME may unwittingly compromise onco-
logical outcomes. Since nodal metastases occur in
0–12 per cent of T1 cancers and 12–28 per cent of
T2 lesions,56,60 there is a possibility of undetected
nodal involvement, even in T1 tumours. Inaccu-
racies in staging can result in undertreatment of
occult cancer spread to the mesorectum, mesenteric
lymph nodes or other sites. Such undertreatment
will inevitably result in increased local recurrences
and decreased survival that likely would not have
occurred had standard radical resection been used.
Whether the technique of EPMR can overcome this
shortcoming in staging lymph nodes accurately
remains to be seen.9,44
These facts simply reflect the state of current
medical knowledge and cannot be used as an
HEBK001-C11_p171-190.indd 185
Follow-up and salvage therapy  185
excuse to avoid a rigorous evidence-based decision-­
making process for each patient presenting with
rectal cancer. This admonition is especially relevant
to the controversies regarding choice of LE versus
radical resection for rectal cancer.
Although the issues regarding appropriate choice
of curative intent LE to avoid over- and undertreat-
ment are not resolved, pretreatment review by a
multidisciplinary team of rectal cancer experts from
different disciplines (colorectal surgery, medical
oncology, radiation oncology, pathology, diagnostic
radiology) is recommended to minimize the risk of
personal bias or incorrect interpretation of imaging,
pathology and other relevant data (Figure 11.3). In
addition, this approach couples the pretreatment
assessment with the skill, experience and judgement
of the treating physicians who have knowledge of
locally available treatment modalities and outcomes
achieved in the past as well as the patient’s specific
situation. Intent of therapy (curative or palliative)
and the occasional need to compromise a preferred
treatment for a patient whose comorbidities create a
prohibitive operative risk for radical surgery can be
clarified. A final recommendation for the patient’s
treatment can be made, informed consent can be
obtained and a treatment protocol implemented.
Follow-up and salvage
therapy
The first decision to make following curative
intent LE of a rectal cancer is whether the intend-
ed goal is likely to have been achieved. Borschitz
and colleagues evaluated and compared oncologi-
cal outcomes of patients undergoing immediate
reoperation versus salvage surgery after LE in the
setting of unsuspected T2 disease or unfavourable
­histology.30,31 At a median follow-up of 10 years,
patients who underwent salvage surgery had sig-
nificantly higher recurrence rates (37 per cent v.
8 per cent) and significantly lower tumour-free
survival (54 per cent v. 86 per cent). The median
time to local recurrence for patients undergoing
salvage surgery was 12 months. Lee and colleagues
also reviewed the outcomes of 36 patients with
unfavourable histology and positive resection mar-
gins who underwent TEM.72 Of the 36 patients, 12
underwent salvage surgery and 24 either refused
radical resection or had poor functional status and
08/02/13 5:37 PM
 186  Local excision and transanal endoscopic microsurgery

CT, computed tomography; ERUS, endorectal ultrasound; LE, local excision; MRI, magnetic resonance imaging;
SM1, superficial (third) submucosal invasion; TAE, transanal excision; TEM, transanal endoscopic microsurgery; TME,
total mesorectal excision.

Figure 11.3. Multimodality treatment algorithm for early rectal carcinoma.

would not tolerate a major operation. Of the 12
patients who underwent salvage surgery, 1 had sys-
temic recurrence. Of the 24 patients who did not
have radical surgery, 5 had recurrence (3 local, 2
distant). Thereafter, many have supported the role
of immediate salvage surgery after TEM in patients
with unfavourable histology, positive excision mar-
gins and a threatened resection margin (, 1 mm),
reducing the recurrence rate to 6 per cent.73
Based on such data, most surgeons agree that if
final pathology after LE or TEM does not confirm
a rectal cancer with the anticipated favourable fea-
tures and with clear margins (i.e. deeper invasion
than anticipated, unfavourable histology features or
a positive margin), then further treatment is indi-
cated, by radical resection or chemoradiotherapy,
or both. A potential concern when LE has to be
converted to radical resection with TME is that of
a violated mesorectal plane, which may result in a
suboptimal TME. Although recurrences after TME
reoperation have been reported, they are infre-
quent. We have found that radical reoperation a few
weeks following LE has been safe.
There is no agreed best practice protocol to fol-
low patients long term after apparent successful LE
of rectal cancer. Since local recurrence is a major
concern following LE of rectal cancer, it would seem
reasonable to regularly perform digital rectal, proc-
toscopic and ERUS examinations. Unfortunately,
even with careful follow-up, it is difficult to detect
residual disease as a curable local recurrence. Many
tumours recur with unresectable local tumours or
incurable distant metastases. Patients who are able
to undergo curative intent therapy often require
multimodality therapy with chemoradiotherapy
and extensive resections. Five-year survival rates
range from 50 per cent to 58 per cent after salvage
surgery and are well below what is expected after
initial radical surgery with TME. At the University
of Minnesota, we followed patients after LE with

HEBK001-C11_p171-190.indd 186 08/02/13 5:37 PM


digital rectal examination, proctoscopy and ERUS
every 4 months. Despite this intensive surveillance,
27 of the 29 patients (93 per cent) we identified
with recurrence after LE presented with advanced
disease (stage II or higher).24 Curative resection
(R0) was possible in only 79 per cent of patients. Of
note, 81 per cent of the patients were asymptomatic
at the time of their diagnosis.
Surgeon’s philosophy
Given the controversies and evolving data regarding
the use of curative intent LE or TEM, it is not sur-
prising that colorectal surgeons have widely varying
philosophies about their roles in normal-risk indi-
viduals with rectal cancer. Some surgeons, discour-
aged by our current inability to accurately stage the
T and N stage of rectal cancer in the pretreatment
evaluation and chastened by the data revealing
compromised oncological outcomes, totally reject
endoanal LE or TEM as a viable option for all but
compromised or palliative situations because of the
fear of undertreating a potentially curable rectal
cancer. They argue that radical surgery with TME
is the treatment of choice for all rectal cancers,
including stage I lesions.
Of the surgeons who do use curative intent LE or
TEM, most attempt to restrict their use at least as sole
therapy to highly selected, low-risk, small, T1 N0 M0
rectal cancers. They argue that despite the inaccuracies
in our best current imaging studies, they can usually
avoid the significant risk of lymph node metastases
in T2 cancers and the significant morbidity of radi-
cal surgery. Other surgeons attempt to be even more
restrictive by limiting curative intent LE or TEM to T1
cancers with sm1 invasion and otherwise favourable
features. The problem is that this approach assumes,
incorrectly, that we have reliable ways to identify pre-
cise levels of T stage and can accurately assess lymph
node metastases before treatment. These surgeons
often view the initial LE or TEM as a first step in the
treatment of such lesions. If final pathology after LE or
TEM does not confirm a rectal cancer with the antici-
pated favourable features and with clear margins, they
then proceed with further treatment by radical resec-
tion or chemoradiotherapy, or both. Whether this
approach compromises survivorship that may have
been achieved had more aggressive therapy been used
initially is debated.
HEBK001-C11_p171-190.indd 187
CONCLUSION  187
Strong advocates for the expanded use of LE
or TEM for more advanced lesions emphasize the
small but significant mortality, the high morbid-
ity, the long-term functional disabilities and the
slow recovery associated with traditional radical
resection. By contrast, they point to the negligible
mortality, low morbidity, generally excellent func-
tion and prompt return to normal life activities
after LE or TEM. They note also that many stud-
ies have shown no significant difference in survival
and that new techniques, including the minimally
invasive sampling of mesorectal nodes and combi-
nation therapy with chemoradiotherapy, may offer
expanded opportunities and improved oncological
outcomes for these approaches.
Endoanal LE or TEM may also be offered to
patients who are medically unfit for a major opera-
tion or who refuse radical resection or a colostomy,
with the option of pre- or postoperative chemo-
radiotherapy. In the setting of palliative excision,
however, most primary tumours are bulky or sten-
otic and may not be amenable to LE.
Conclusion
The ideal therapy for rectal cancer cures the patient
of the primary lesion and any distant metastases
without treatment-related mortality or major mor-
bidity, while preserving pretreatment bowel, sexual
and urinary function and allowing prompt return
to a high quality of life. Over- and undertreatment
are avoided. Unfortunately, the ideal is often not
achievable, in part because there are numerous
other factors still to be elucidated, such as tumour
biology, tumour–host interactions and genetics,
which if known may influence our decisions and, in
part, because the information on which we base our
decisions is less than complete and less than totally
accurate.
The appropriate role of endoanal LE or TEM,
or newer modifications of these techniques, for
treatment of rectal cancer is highly controversial.
Although radical resection with TME continues to
be the standard operation for most patients with
rectal cancer, endoanal LE and TEM are acceptable
alternatives, with significantly less morbidity. Most
surgeons restrict their curative intent use to selected
patients with T1 disease or to patients unfit for radical
resection. Compared with endoanal LE, TEM offers
08/02/13 5:37 PM
 188  Local excision and transanal endoscopic microsurgery
a higher likelihood of achieving clear resection mar-
gins, lower recurrence rates and the ability to success-
fully excise more proximal tumours. Although the
number of studies comparing endoanal LE or TEM
to radical resection with TME is small, the results are
similar, in the sense that both show a higher recur-
rence rate, a trend towards decreased survival, and
lower morbidity with LE techniques compared with
radical resection. Significant disease progression can
occur after LE despite intense surveillance, which
may preclude curative salvage. The role of chemora-
diation therapy and LE techniques in the treatment
of rectal cancer is still under study.
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08/02/13 5:37 PM

Pathology assessment
Philip Quirke, Tim Palmer, Gordon G.A. Hutchins and Nick P. West
Introduction
Pathologists play a key role in the multidisciplinary
team management of rectal cancer. The patho-
logical analysis of the excised specimen provides
important prognostic information on the stage of
the tumour, the accuracy of radiology and the qual-
ity assurance of the surgery. Quality assurance ema-
nates from reporting the completeness of tumour
excision and the precise planes of excision, as rep-
resented by the macroscopic appearance of the
specimen. The pathologist can assess the response
to preoperative therapy and help to determine the
need for postoperative or adjuvant therapy, either
radiotherapy or chemotherapy. The pathologist can
also identify patients at high risk of metachronous
disease and screen for possible hereditary non-
polyposis colorectal cancer using immunohisto-
chemistry for mismatch repair gene expression.
Pathology may also help to educate radiologists and
assure the quality of their reporting. More recently,
pathologists have undertaken further molecular
testing to help predict the type of therapy that may
be effective; for example, Ki-ras mutations may be
used to predict response to anti-epidermal growth
factor receptor (anti-EGFr) antibodies. The cur-
rent era is moving into whole-genome sequencing,
which will have far-reaching implications for the
diagnosis, prognosis and treatment of colorectal
cancer. A further crucial responsibility is submis-
sion of high-quality pathology reports, preferably
HEBK001-C12_p191-202.indd 191
12
via electronic proformas, to cancer registries so that
the work of individuals, teams and institutions can
be compared nationally and internationally and so
that excellent and potentially suboptimal practice
can be identified.
Applied anatomy
The rectum is situated with the confines of the
bony pelvis and adjacent to important structures.
The pelvic autonomic nerves run very close to the
perimesorectal resection planes, the ureters are
located laterally, and the prostate in male patients
and the posterior vaginal wall in female patients
are in close proximity to the anterior surface of the
rectum. The sigmoid and upper and middle rec-
tum are encased in peritoneum, which decreases
in extent distally, but anteriorly at the peritoneal
reflection the surgeon must incise the peritoneum
and create the anterior surgical plane that is so
critical to a successful surgical operation. Posteri-
orly the surgeon enters the perimesorectal fascial
plane, following either the visceral or the parietal
plane. This can be distinguished by the thickness
of the fascia applied to the mesorectum. The fas-
cia blends with the peritoneum laterally above the
peritoneal reflection, enclosing the surgical ‘pack-
age’, which needs to be removed intact. Posteriorly,
deep within the mesorectum, close to the mesorec-
tal fascial surgical circumferential resection margin
08/02/13 5:36 PM
 192  Pathology assessment
(CRM), is the ­superior rectal artery and its division
into its left and right branches. This artery is impor-
tant because lymphatic drainage is associated with
the arterial blood supply and lymph nodes can be
found clustered near to the artery and adjacent to
the mesorectal fascia.
The mesorectum narrows superiorly in its cranial
portion, bulges at the level of the mid-rectum and
then narrows to taper out at the puborectal sling.
The levators are applied to the lowest part of the
mesorectum and can be taken with the mesorectum
when excising low rectal cancers or large cancers
involving the anal canal. The anatomy of the anal
sphincters varies between individuals, with variable
bulk of the muscle layers and differing anal canal
lengths. It is a highly complex evacuation control
mechanism and deserves further anatomical study.
The intersphincteric plane, an important potential
surgical plane between the internal and external
sphincters, can be used to achieve a very low recon-
struction with partial or even complete removal of
the internal sphincter, thus avoiding the need for
abdominoperineal excision (APE).
The anatomical structures of the anal sphincter
are not well known by pathologists but are wor-
thy of detailed study to analyse and improve low
rectal cancer surgery and to accurately stage these
tumours. Radiologists, surgeons and pathologists
are increasingly skilled at understanding the ana-
tomical relationships of rectal cancer; optimal pre-
operative images help in providing the anatomical
road map for the surgeon to plan the appropriate
planes for surgical intervention. The pathologist
can then determine how closely the surgeon fol-
lowed the intended plane.
The circumferential margin
In 1982, while discussing the mismatch between
the infrequently observed involvement of the dis-
tal margin of resection and the high rate of local
recurrence in rectal cancer, we decided to look
at the ‘lateral’ surgical margins on the resected
specimens, i.e. the margin created by the surgeon
around the rectum. It rapidly became apparent
that this margin, initially referred to as the ‘lateral
resection margin’ and subsequently termed the
‘circumferential resection margin’, was frequently
involved in rectal cancer. Fifty-two cases were ana-
HEBK001-C12_p191-202.indd 192
lysed, all patients were followed up for 2 years and
the outcomes were published in 1986.1 Just before
this, Chan and colleagues from Hong Kong pub-
lished 50 cases showing tumour involvement of the
same margin but without clinical follow-up.2 We
were able to demonstrate the importance of this
margin as a cause of local recurrence (although
‘progressive persistent disease’ might be a more
accurate term). We reported the high frequency of
local recurrence and the importance of a margin
greater than 1 mm rather than 0 mm, as had previ-
ously been the gold standard. From this emanated
the concept of an involved margin where tumour
was found within 1 mm of the surgical resection
margin. This initial 1986 publication was followed
by reports on two larger series3,4 and by others
summarized in a review article.5
The principles of CRM involvement have been
documented in numerous studies, including many
prospective randomized trials (Dutch Total Mes-
orectal Excision (TME) Trial, Medical Research
Council (MRC) CR07 Trial, MRC Conventional
versus Laparoscopic-Assisted Surgery in Colorec-
tal Cancer (CLASICC) Trial) and have confirmed
the importance of a positive or negative CRM.
More recently, a meta-analysis was reported,5 and
even with a group of mesorectal trained surgeons it
retains its importance.6,7
Involvement of the CRM occurs most frequently
anteriorly, where the mesorectum is at its thin-
nest. Additionally, the CRM is at high risk in the
low mesorectum from surgical coning at the pub-
orectalis and sphincter muscles when the surgeon
undertakes standard APE. Anteriorly there is the
least tissue surrounding the muscle tube,8,9 and fol-
lowing the intended plane under excellent direct
vision is essential. For advanced posterior and lateral
tumours, removing the levators, or if appropriate the
ischiorectal fat, can increase the potential clearance.
Tumour involvement either at the margin or
1 mm or closer to the margin carries the highest
risks of local recurrence,5,10 and this risk decreases
as the distance increases between the tumour and
the resection margin. The mode of margin involve-
ment does not seem to matter and can be by direct,
discontinuous, venous, lymphatic or neural spread.4
The presence of tumour within a lymph node with-
in 1 mm of the margin does not appear to confer
as high a risk in the two small series identified, but
the database on this is very small. These areas are
08/02/13 5:36 PM

reviewed elsewhere,5 but the hypothesis is that if
the tumour is confined to lymphatic pathways, then
spread will be within this system and will thus be
upwards towards higher nodes rather than towards
the CRM. This does, however, depend on the sur-
geon removing the TME plane perfectly.
The importance of an involved CRM increases
after preoperative treatment, with an increase in
the risks of local failure,5,11–14 and there is a strong
association with an increased local recurrence but
an equivalently poor survival. Achieving a complete
excision locally is essential in the curative man-
agement of rectal cancer. Although preoperative
treatment helps to achieve a clear margin in some
advanced cases, if the margin is involved after neoad-
juvant therapy the outcome is poor. It has been pro-
posed that consideration should be given to the strat-
egy of trying alternative chemotherapy approaches
to achieve down-staging before intervening with
definitive radiotherapy and subsequent surgery. The
delivery of induction chemotherapy before chemo-
radiotherapy in the Expert C trial appears to provide
additional down-staging,15 and in patients resist-
ant to the first therapy an alternative combination
may be tried before adding radiation. An alternative
approach is being studied by the Swedish trialists,
where 6 weeks of chemotherapy is given following
short-course radiotherapy. These approaches are still
experimental and being evaluated.
Planes of surgery
Heald and colleagues described TME in 198216 and
excellent outcomes in 1986.17 Subsequent audit
of these results confirmed the survival benefit of
this operation in highly skilled hands.18 The differ-
ences in specimen appearances and surgical planes
of standard anterior resection and Heald’s TME
specimens became apparent when Quirke, Heald
and others participated in a pathological dissection
workshop in 1993 in Oslo as part of the Norwegian
rectal cancer education courses. Total mesorectal
excision achieves a smooth surgical margin by fol-
lowing the anatomical plane provided by the outer
surface of the mesorectal fascia. The standard sur-
gical planes achieved by the Norwegian surgeons
at that time were either on the muscularis propria,
where the surgical excision extended down on to
the muscularis propria; intramesorectal, where the
HEBK001-C12_p191-202.indd 193
PLANES OF SURGERY  193
plane was within the mesorectum; or mesorectal,
where the planes were followed accurately. Coning
of the specimen near to the distal excision mar-
gin was also frequent, bringing the surgical CRM
closer or into the area of the cancer. This classifica-
tion into mesorectal, intramesorectal and muscu-
laris propria specimen descriptions was developed
from these observations.19,20 The classification was
assessed prospectively by local pathologists in the
MRC CR07 trial21 and retrospectively by central
review of photographs in the Dutch TME Trial.22
Both studies demonstrated that the plane of sur-
gery was related to local recurrence; additionally,
the Dutch study showed the plane of surgery was
related to survival. Three further studies have con-
firmed the relationship between specimen quality
and local recurrence.23–25 Unsurprisingly, the plane
achieved was related to CRM positivity rates,
with the lowest positive CRM rates in mesorectal
plane surgery. The specimen plane was not relat-
ed directly to the stage of the tumour, with many
suboptimal specimens in early-stage tumours. The
frequency of CRM involvement and the plane of
surgery have been documented in the Magnetic
Resonance Imaging in Rectal Cancer European
Equivalence (MERCURY) study,7 with the lowest
CRM positivity in mesorectal plane excisions and a
higher rate of mesorectal excisions than seen in the
MRC CR07 study. Surgeons showed improvement
in the frequency of mesorectal excisions over the
trial. There was an additive effect of radiotherapy
on all grades of surgery; with this combination,
good surgery led to a 1 per cent local recurrence
rate compared with 6 per cent in patients who
received no irradiation.21
In many studies, the quality of surgery was much
poorer in APE specimens. There was no improve-
ment in quality over the period of the trial in CR07
in APE, whereas there was an improvement in qual-
ity in anterior resection. Thus, achieving optimal
planes improves outcomes in patients with rectal
cancer undergoing anterior resection; focusing on
this during surgery, and its subsequent pathologi-
cal assessment, has major benefits to patients. This
can be seen in the reduction in local recurrence
rates and improving survival rates seen in rectal
cancer where such techniques have been adopted in
­Norway,26 Stockholm,27 the Netherlands,28 Vancou-
ver29 and British Columbia;30 many other results are
expected over the next few years.
08/02/13 5:36 PM
 194  Pathology assessment

Table 12.1. CRM involvement in anterior resections moted by Holm.37 The concept of this operation
compared with abdominoperineal excisions. involves removing the levators attached to the
Abdominoperineal Anterior lower mesorectum and the entire anal canal with
Study n excision (%) resection (%) internal and external sphincters and a greater or
Marr et al. 10
686 36.5 22.3 lesser degree of ischiorectal and ischioanal fat.
Taylor et al.6,7 282 33 13 This occurs under direct vision, with the patient
Nagtegaal et al. 22
1586 29 13
in the prone position for the perineal part of the
procedure. The supine position has also been
Guillou et al.31 400 21 10
promoted with an emphasis on excellent direct
M. Peters, 21 10
vision.38 This approach can provide the criti-
 personal
cal few extra millimetres of protection around a
communication,
­locally advanced low rectal tumour and prevent
2008
perforation of the anal canal.
Quirke et al.21 1350 17 8 Holm has categorized excision of the sphincters
Wibe et al.32 2136 12 5 and anal canal into three types of operation: the
standard APE, with its perilous waist, high margin
positivity and high perforation rates; the extraleva-
Abdominoperineal excision tor APE, where the levators are removed en bloc;
and the extended extralevator APE, with a unilat-
The outcome after APE for rectal cancer is generally eral or bilateral extension into the ischiorectal fossa,
inferior to that after anterior resection, with an 8–10 dependent on the local extension of the cancer.
per cent worse overall survival in many studies. The latter is more commonly needed for advanced
The main cause appears to be related to the high recurrent squamous cancer, although on occasions
CRM positivity (Table 12.1) and specimen perfora- it may be required for very advanced adenocarci-
tion (Table 12.2) rates in APE. noma. Any of these operations can include removal
This may be explained on the basis of the sur- of other local organs such as the posterior wall of
gical planes used when resecting these tumours. the vagina in female patients or variable amounts
This aspect of APE specimens was first identi- of the prostate in male patients.
fied in 200236 and subsequently verified in a joint A study compared the specimens from Holm’s
study of the APE specimens in the Dutch TME extralevator operation with the standard opera-
Trial.33 In the latter study, a third of cases showed tion APE specimens from our own institution in
the surgical plane to extend into the lumen, sub- Leeds and demonstrated a markedly reduced CRM
mucosa or internal sphincter. In the other two- positivity and perforation rate.8 An increase in the
thirds of cases, the typical ‘waist’ seen in most amount of tissue removed by extralevator surgery
standard APEs was noted. A solution to reduce compared with standard surgery was also docu-
margin involvement and specimen perforation mented. These studies were extended to collect ext-
was identified at the Karolinska Institute, Stock- ralevator specimens from colleagues in the UK and
holm, when the concept of what is now termed Europe and found identical results, with a drop in
an ‘extralevator APE’ was performed and pro- margin involvement and specimen perforation.9
On reviewing the literature, it also became appar-
ent that there were other units in Paris and Wroclaw
Table 12.2. Perforation rates in anterior resections that used this approach. The Hôpital St Antoine in
compared with abdominoperineal excisions. Paris reported excellent outcomes, with 10 per cent
Abdominoperineal Anterior local recurrence in all patients and 5 per cent in cur-
Study n excision (%) resection (%) ative excisions and a 5-year survival of 76 per cent
Nagtegaal et al.33 1586 13.7 2.5 after APE for rectal cancer.39 Discussions with the
Wibe et al. 32
2136 16 4
authors and photographic proof from Emmanuel
Tiret and Roland Parc confirmed that they adopted
Eriksen et al.34 2873 15.4 3.6
an extralevator approach. Similarly, Bebenek has
Stockholm audit35 613 12 4
reported what he terms ‘abdomino-sacral APE’

HEBK001-C12_p191-202.indd 194 08/02/13 5:36 PM


with excellent results of 8 per cent CRM positivity,
4 per cent perforation, 4.4 per cent local recurrence
and 5-year survival of 68 per cent in more advanced
stage low rectal cancers.40
Thus, there are now substantial data on the
problems of the ‘standard’ APE and accumulat-
ing evidence of the superiority of the extraleva-
tor approach to APE.9 Ongoing issues pertain to
patient selection, the optimum approach, whether
prone or supine,38,41 whether open, laparoscopic42,43
or robotic,44 and the best methods of closing the
pelvic floor to optimize wound healing and reduce
perineal hernias.45,46 While awaiting the outcomes
of these issues, however, the potentially avoidable
local recurrences and impaired survival from stand-
ard APE should not be discounted. The National
Health Service in England has commissioned a
pilot programme on training and education in this
area for English multidisciplinary teams (www.
lorec.nhs.uk), and there are similar initiatives in
Denmark and other health-care systems.
Reporting rectal cancer
Accurate reporting of rectal cancer specimens is
crucial because the details may have a major impact
on the multidisciplinary management of what is a
complex and common cancer. It is therefore impor-
tant to ensure that adequate time and resources are
available to undertake this task. Pathologists need
to feel like an important component of the team,
and to have seen good-quality TME and extral-
evator APE specimens so that they understand the
anatomy and potential surgical planes that they
need to evaluate and categorize. Ideally, patholo-
gists should understand the magnetic resonance
imaging (MRI) images so that preoperative scans
can guide specimen dissections and provide accu-
rate feedback to radiologists, surgeons and others
in the multidisciplinary team. Increasingly, radiolo-
gists can accurately describe the site of the tumour,
and report the distance between the margin of the
tumour or tumour deposit and the CRM, whether
this is the mesorectal fascia, levators, anal sphinc-
ters, ischiorectal fat or other structures. The dis-
tance from the muscularis propria to the edge of
the tumour, and large vessel extramural vascular
invasion, may also be recordable; on occasion, peri-
toneal involvement may be documented.
HEBK001-C12_p191-202.indd 195
REPORTING RECTAL CANCER  195
The accuracy of MRI with regard to nodal
deposits is debatable, as larger nodal size does not
always equate with tumour involvement and many
nodal deposits are in small lymph nodes. Indeed,
large nodal size can equate with a better immune
response and thus a better outcome. The texture
of nodes and their irregularity may give a better
indication of involvement, but it is still suboptimal.
The MRI images provide a surgical road map for
the operation, but it is important to note that inac-
curate calling of MRI images can have a profound
impact on patient treatment, with either over- or
under treatment as a consequence.
Preparation of the Specimen
The following preparation and dissection notes
were prepared for the National Cancer Research
Institute (NCRI) Aristotle trial (see www.control-
led-trials.com/ISRCTN09351447) and are very
similar to those used within the Low Rectal Can-
cer and MERCURY studies. They should be used
in conjunction with the Royal College of Patholo-
gists’ dissection guidelines and the reporting pro-
formas (see www.rcpath.org/Resources/RCPath/
Migrated%20Resources/Documents/G/G049-
ColorectalDataset-Sep07.pdf and www.rcpath.org/
Resources/RCPath/Migrated%20Resources/
Documents/G/G049ColorectalDatasetAppendixC-
Sep07.doc). Whether the specimen is received fresh
or fixed, the handling should be equivalent. Before
opening the specimen, the anterior and posterior
surfaces should be photographed to document
the quality of removal by assessing the anatomical
planes that have been achieved. Close-up images
of the front and back of the levator/anal sphincter
facilitate assessment of extralevator APE specimens.
Each photograph should include a centimetre scale
placed beside the specimen. The pathologist should
grade the quality of the surgery for both the mes-
orectum and the levator/anal sphincter area. It is
advantageous to paint the surgically created mar-
gin as early as possible to allow the dye to adhere to
the specimen as securely as possible so it does not
spread widely on dissection. The adherence of the
dye increases with the length of fixation.
The specimen can then be opened from the prox-
imal margin distally to 2–5 cm above the tumour.
The distal end should be kept intact. If the specimen
08/02/13 5:36 PM
 196  Pathology assessment
is received unfixed, and fresh material is required
for storage or research, it should be taken at this
stage. The tumour can be everted through the upper
anterior specimen incision and luminal tumour
removed, or a jumbo biopsy forceps can be used to
obtain tumour material. A piece of foam or tissue
paper soaked in formalin can be inserted through
the tumour if appropriate to improve fixation; if
received fixed, the specimen can be inflated with
formalin and sealed at both ends. The specimen can
then be placed in formalin.
Before dissection it is acceptable to inflate the
specimen with formalin, fix and then take photo-
graphs. The anterior surface of the tumour should
never be opened as it destroys the assessment of the
anterior CRM, the area most frequently involved
by cancer by direct invasion, peritoneal involve-
ment or perforation. The luminal size or area of the
tumour does not convey prognostic information.
The anterior high rectum is covered by peritoneum;
this area, especially the paracolic gutters, should
be inspected carefully for peritoneal involvement.
Although peritoneal involvement is an adverse
prognostic indicator, peritoneal involvement does
not constitute an involved CRM, as this is not a sur-
gically created margin.
Dissection
Consideration should be given to enhancing the
lymph node yield by the use of methylene or pat-
ent blue injection47 into the artery at the time the
specimen is removed by the surgeon, or by use of
glacial acetic acid, ethanol, distilled water and for-
maldehyde (GEWF) fixation48 or post-dissection
using xylene clearance.49,50 This can be especially
useful for post-treatment resections where nodal
size is reduced.51,52
Anterior and posterior non-peritonealized sur-
faces are painted with ink. It should be remembered
that the CRM applies only to the surgically incised
mesorectal planes and not the peritonealized sur-
faces. The mesorectal surface is larger posteriorly
and extends up to a higher level than it does ante-
riorly. After the resection surfaces have been inked,
the specimen is fixed in formalin for a minimum of
48 h, but longer if possible. The firmer the mesorec-
tum after fixation, the thinner the slices can be and
the more thoroughly the tumour can be examined.
HEBK001-C12_p191-202.indd 196
The macroscopic description should be complet-
ed, specifically noting the presence of a perforation
of the tumour or mucosa and the site of the perfora-
tion. It should be stated whether the tumour perfora-
tion is present in an area covered by peritoneum or
a surgical margin, and whether it is above or at the
level of the sphincters. The presence or absence and
completeness of the attachment of levator ani to the
mesorectum on the specimen should be described.
The descriptions of grading are given below.
The specimen should be sliced as thinly as pos-
sible, starting from the distal margin to 2–5 cm
above the tumour. These slices should be laid out
in good light, starting with the most distal slice at
the top left-hand corner, and the most proximal
slice ending up as the last slice. The face presented
to the camera should be consistent in all the slices.
The slices should be photographed including a cen-
timetre scale.
The minimum distance of the tumour to the
CRM should be described, as should the maximum
depth of invasion through the muscularis propria
and the structures invaded by the tumour.
If the CRM is free of tumour, it should be not-
ed whether there is normal tissue at the margin
or whether it is fibrotic tissue following tumour
regression potentially indicating a previously
involved margin.
If the CRM is involved (confirmed on histology),
then the mode of involvement and the distance of
involvement at that site should be stated (e.g. small
area measuring 2 mm or more extensive involve-
ment measuring 10 mm).
It is preferable to sample the main tumour by
embedding each tumour-bearing slice and cutting
one to four large mount sections, although this is
not possible in many laboratories; where it is not
possible, it is important to ensure that a minimum
of five blocks of tumour are taken, including the
CRM where the tumour is close and any other
important macroscopic pathology (see below).
As many lymph nodes as possible should be
dissected from the specimen. Lymph nodes after
preoperative therapy are generally smaller and fre-
quently around 1 mm in size; this should be borne
in mind, as they will be more difficult to locate. The
use of methylene blue injection or GEWF fixation
will increase the number of nodes found.
Involvement of the peritoneum is defined as per
Shepherd and colleagues’ recommendations.53,54
08/02/13 5:36 PM
 REPORTING RECTAL CANCER  197

Extramural vascular invasion (EMVI) is defined the grade for the mesorectum. For APE, there will be a
by involvement of a thick vascular structure with grade for the mesorectum and another grade for the
a smooth muscle wall that will contain elastin on levator and anal canal area below the mesorectum.
elastic staining. This should be looked for closely.
If an isolated tumour deposit is present close to an
arterial structure, without an accompanying vein, Quality of Resection of
consider vascular invasion. Increased reporting fre- the Mesorectum
quencies of EMVI have been found following the
addition of elastic staining to haematoxylin and The quality of a mesorectal resection can be easily
eosin.55,56 assessed macroscopically and graded as shown in
Table 12.3.
This classification has been used in several series
T Staging of Low Rectal Cancers and two trials. The plane of surgery correlates with
frequency of CRM positivity, with the lowest CRM
The T staging of cancers above the sphincters is positivity rates in mesorectal plane excision speci-
straightforward and is the same as that for colon can- mens and the highest rates in muscularis propria
cers. As some mid-rectal and all low rectal adenocar- excision specimens.
cinomas have a proportion of the lesion within the
region of the sphincters, however, T staging is prob-
lematic. Currently, T staging of adenocarcinoma in Quality of Resection in
the area of the sphincters is unsound. TNM 7 states
that such tumours should be staged as anal cancers
Abdominoperineal Surgery
by tumour size. In the absence of a robust staging
The quality of surgery of the levator/anal canal area
system, the only solution is to describe the maximal
below the mesorectum can be assessed as shown in
anatomical extent of spread, both above the sphinc-
Table 12.4.
ter and at the level of the sphincter separately, to
allow subsequent analysis. We propose that the maxi-
mum level of invasion above and at the level of the Table 12.3. Summary of mesorectal grading.
sphincter should be recorded separately by extent of
Fascial plane Description
maximal spread. This should be captured by describ-
Mesorectal The mesorectum is smooth, with no violation
ing the extent of spread (e.g. submucosal, internal
 of the fat and good bulk to the mesorectum
sphincter, intersphincteric space, external sphinc-
anteriorly and posteriorly. The distal margin
ter) and also measuring the extent of spread from
appears adequate, with no coning near the
the muscularis propria and, where applicable, from
tumour. No defect is more than superficial
the edge of the internal sphincter when a tumour
or 5 mm deep.
involves the sphincters. We need to know whether
Intramesorectal There is moderate bulk to mesorectum but
one or both sphincters are involved by tumour. This
 irregularity of the mesorectal surface. There
is relatively easy to do, as the internal sphincter is an
is moderate coning of the specimen towards
easily identified reference point, being composed of
the distal margin. At no site is the muscularis
pearly-white smooth muscle. Involvement of striated
propria visible, with the exception of the
muscle indicates involvement of the levators, pub-
area of insertion of levator muscles. There is
orectalis or external sphincter.
moderate irregularity of the CRM.
Muscularis There are areas of substantial loss of
Assessment of Quality   propria  mesorectal tissue. Deep cuts and tears

of Surgery: Grading down on to the muscularis propria are

present. On cross-section there is a
very irregular CRM, with little bulk to the
The mesorectum and the anal canal/levator parts of
mesorectal fat; the muscularis propria forms
the specimen should be graded separately. For an ante-
the CRM in places.
rior resection specimen there will only be one grade –

HEBK001-C12_p191-202.indd 197 08/02/13 5:36 PM

 198  Pathology assessment
Table 12.4. Summary of abdominoperineal excision grading.
Plane Description
Levator The surgical plane lies external to the levators,
 with the levators being removed en bloc
with the specimen. This creates a cylindrical
specimen with the levators forming an extra
protective layer on the sphincters.
Sphincteric Either there are no levator muscles attached
 to the specimen or there is only a very small
cuff and the resection margin on the surface
of the sphincters. The specimen has a
waisted/apple-core appearance.
Intrasphincteric/ The surgeon has inadvertently entered the
  submucosal  sphincters or even deeper into the submucosa
or perforated the specimen at any point.
For an anterior resection specimen, there will
be a single mesorectal grade. For an APE specimen
there will be two grades.
Definitions Used in Pathology
Position of tumour
The position of the tumour should be noted accu-
rately. Initially this involves documentation of the
surface involvement (i.e. anterior quadrant, pos-
terior quadrant, lateral quadrant, combinations
of these). To correlate the position with the MRI
report, however, the tumour position should be
­reported from the distal resection margin with the
mesorectum posteriorly and the peritoneal reflec-
tion anteriorly. This can be documented as a rela-
tionship to a clock face on the reporting proforma,
with anterior at the 12 o’clock position (e.g. ‘maxi-
mal extent of tumour present between 10 o’clock
and 3 o’clock’).
Relationship to peritoneal reflection
A crucial landmark for recording the site of rectal
cancers is the peritoneal reflection. This is identified
from the exterior surface of the anterior aspect of
the specimen. Rectal cancers are classified accord-
ing to whether they are:
l entirely above the level of the peritoneal reflec-
tion anteriorly;
l astride or at the level of the peritoneal reflection
anteriorly;
HEBK001-C12_p191-202.indd 198
l entirely below the level of the peritoneal reflec-
tion anteriorly.
Relationship to circumferential resection margin
Anteriorly the upper rectum is covered by perito-
neum. Only the area below the peritoneal reflection
is at risk of surgical CRM involvement. Posteriorly
this area and the area above it, a triangular bare area
running up to the start of the sigmoid mesocolon,
is at risk not only from direct tumour spread but
also from metastatic deposits in lymph nodes that
lie against the circumferential margin.
It is recommended that the whole of this mar-
gin (i.e. the mesorectum) be painted with a marker
such as India ink or Alcian blue followed by acetic
acid to fix the dye on the surface before dissecting
the specimen. The tumour is then best sliced seri-
ally at 3- to 4-mm intervals to select blocks from the
area above and below the tumour to look for meta-
static deposits. If lymph nodes lie against the cir-
cumferential margin, then these should be included
in the block.
Relationship to extent of extramural
invasion of tumour
When assessing the relationship to the CRM, on the
whole-mount section the corresponding relation-
ship between the outer surface of the muscle coat
and the maximum depth of extramural invasion
needs to be measured. This is performed using the
Vernier scale on the microscope or by overlaying a
scale on the microscope slide.
Lymph nodes
All lymph nodes found in the specimen should be
sampled and counted, regardless of their site and
size. The number of positive lymph nodes must be
equal to or less than the number of lymph nodes
sampled.
Extramural tumour deposits measuring 3 mm or
larger are counted as involved lymph nodes, even if
no residual lymph node structure can be identified,
as defined in TNM 5. If lymph nodes are present
but the structure cannot be discerned, the pres-
ence of satellite nodules should be recorded as well.
Smaller satellite deposits are regarded as apparent
discontinuous extensions of the main tumour, and
their presence should be recorded.
In TNM 5, pN1 (where ‘p’ corresponds to ‘patho-
logical’) denotes involvement of one to three nodes
08/02/13 5:36 PM

and pN2 denotes involvement of four or more
nodes. We do not recommend using TNM 6 or
7 because of the many issues outlined in several
papers.57–59
Distance to distal resection margin
This is measured from the nearest cut end of the
specimen to the tumour, not the circumferential
margin. It is necessary to examine the margins his-
tologically only if the tumour extends macroscopi-
cally to within 30 mm of the distal or circumfer-
ential margin. For tumours further away from the
margin, it can be assumed that the cut ends are not
involved. Exceptions to this recommendation are
adenocarcinomas that are found on subsequent his-
tology to have an exceptionally infiltrative growth
pattern, show extensive vascular or lymphatic per-
meation, or are undifferentiated carcinomas.
Relationship to dentate line
This can be measured only for low rectal tumours
in APE specimens.
Tumour perforation
If the tumour has perforated into the peritoneal
cavity or through the mesorectal fascia or sphinc-
ter complex, then these cases should be recorded as
a perforation. The TNM staging system states that
only perforation of the peritoneum should be called
pT4, but perforation/surgical rupture of tumour in
such areas confers a poor prognosis34 and many of
them would be reported as pT4 in routine practice
in the UK.
Tumour differentiation
The differentiation of the tumour should be defined
on the dominant area of tumour as well differenti-
ated or moderately differentiated, equivalent to low
grade and poorly differentiated or undifferenti-
ated in the World Health Organization ‘blue book’,57
which is equivalent to high-grade tumour. Other
types of differentiation (e.g. mucinous adenocarci-
nomas, signet ring, undifferentiated) and the pres-
ence of high-grade dysplasia should be documented.
Assessment after preoperative therapy
The prefix ‘y’ indicates either a staging scan or patho-
logical assessment after preoperative (neoadjuvant)
therapy. Such tumours should be staged with the
prefix ‘y’ before pTNM staging. There is no doubt
HEBK001-C12_p191-202.indd 199
REPORTING RECTAL CANCER  199
that lowering the ypT stage is of some value, but the
relative risk/benefit ratio is still uncertain for many
patients. Some studies suggest that it improves out-
come.14 The occurrence of a complete pathological
response (ypT0 ypN0) is very important, as patients
with this finding at pathology have excellent
cancer-related outcomes.58,59 If ypT0 and ypNx are
included as complete pathological response, then
the frequency of complete response increases by
7 per cent. One major issue with complete response
is the pathological dissection and sampling protocol
followed. Lax pathological dissection and sampling
lead to a higher frequency of complete response. For
the Sanofi Capecitabine, Oxaliplatin, Radiotherapy
and Excision (CORE) Trial, an international panel
recommended taking five blocks of tumour and, if
no tumour was identified, to cut three further lev-
els. If tumour is still absent, then the whole area of
abnormality should be embedded and, if necessary,
a further three levels sectioned. If at this stage no
tumour is identified, then this should be considered
a complete response. It is critical for the continued
use of complete pathological response that the sam-
pling is standardized.
The reports of tumour regression grading stud-
ies have been disappointing. Rödel and colleagues
tested regression grading in the German trial. They
failed to show a significant relationship to surviv-
al with five categories and then amalgamated the
groups and obtained significance.60 Gosens and
colleagues13 and Rullier and colleagues14 did not
find any significant benefits correlated to tumour
regression grading. It is clear that a complete
response ypT0 ypN0 has an excellent prognosis
and that good responders, usually regressing to pT1
or early pT2 N0, also have excellent cancer related
outcomes.14 In our experience, it has become appar-
ent that it is impossible to distinguish between no
response and a poor response if looking at rand-
omized trial material blinded to trial arm.
Optimal Reporting
As outlined above, optimal reporting of a rectal
cancer specimen requires extensive knowledge
of the anatomy, radiology, pathology and treat-
ment modalities. Excellent reporting is key for the
best modern management of this disease. Pathol-
ogy reporting goes beyond the crucial benefits to
08/02/13 5:36 PM
 200  Pathology assessment
the individual patient. The pathological findings
allow us to give feedback and audit to radiolo-
gists and surgeons and help oncologists to under-
stand the effects of current and new therapies. This
mechanism creates a virtuous loop of continuous
improvement. Optimal practice and continuous
feedback offers our best hope of improving the out-
comes in colorectal cancer, one of the most com-
mon curable gastrointestinal tract tumours. The
combination of screening, optimal surgery and
appropriate preoperative and adjuvant therapy
should allow us to make inroads into the mortality
associated with this condition.
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12. Luna-Pérez P, Bustos-Cholico E, Alvarado I, et al.
Prognostic significance of circumferential margin
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13. Gosens MJ, Klaassen RA, Tan-Go I, et al. Circum-
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14. Rullier A, Laurent C, Capdepont M, Vendrely V, Bioulac-
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of surgery achieved on local recurrence in patients
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27. Martling AL, Holm T, Rutqvist L-E, et al. Effect of a sur-
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the introduction and training of total mesorectal exci-
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Low rectal cancer: a call for a change of approach in
abdominoperineal resection. J Clin Oncol 2005; 23:
9257–64.
34. Eriksen MT, Wibe A, Syse A, et al. Inadvertent perfora-
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35. Anderin C, Martling A, Hellborg H, Holm T. A popula-
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of resection in low rectal cancer. Dis Colon Rectum
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37. Holm T, Ljung A, Häggmark T, Jurell G, Lagergren J.
Extended abdominoperineal resection with gluteus
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rectal cancer. Br J Surg 2007; 94: 232–8.
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extralevator perineal dissection in supine position for
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M, Tiret E, Parc R. Oncologic results following
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REFERENCES  201
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 202  Pathology assessment
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58. Capirci C, Valentini V, Cionini L, et al. Prognostic value
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59. Maas M, Nelemans PJ, Valentini V, et al. Long-term
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2005; 23: 8688–96.
08/02/13 5:36 PM

Assessment and management
of recurrence
Peter J. Lee, Kirk K.S. Austin and Michael J. Solomon
Introduction
Historically, surgery for locally recurrent rectal can-
cer (LRRC) has not been a widely accepted modality
of treatment. It was believed to incur high morbidity
and mortality. Cancer-related deaths with LRRC are
unpleasant, with intractable pain, offensive perineal
discharge and rectal bleeding, all culminating in a
poor quality of life.1–3 The prognosis of such patients
with incurable or inoperable recurrent rectal cancer
without treatment is invariably poor, with a median
survival of 9 months and less than 5 per cent 5-year
survival.4–6
Surgical resection, defined as pelvic exenteration,
was first described over 50 years ago, but it was not
until the 1990s that substantial case series were pub-
lished. As a consequence, rather than surgical refer-
ral and aggressive treatment, non-invasive palliative
treatments such as chemotherapy or radiotherapy
were implemented. This would relieve symptoms
for only a short term and had a median survival of
10–17 months.2,7,8 Improvements in surgical tech-
niques and postoperative care and the implemen-
tation of multimodality therapy have contributed
to a significant reduction in operative mortality to
somewhere in the region of 1 per cent in specialized
units, but morbidity remains high, at about 30 per
cent.9,10 It is pertinent to note that after pelvic ex-
enteration, patients report an improvement in their
HEBK001-C13_p203-221.indd 203
13
quality of life, with a reduction in pain. In addition,
their quality of life is better than in patients who
receive non-surgical palliative treatment.11–13
Improved surgical techniques and adjuvant ther-
apies for primary rectal cancer have reduced the
rates of local recurrence to less than 10 per cent.14
Surgery for LRRC, or pelvic exenteration surgery,
has become more complex, requiring more radical
extended surgery and the involvement of a multi-
disciplinary team approach.
The most important factor in exenteration surgery
is to achieve a microscopically clear (R0) resection
margin.4,9,10,15–18 Exenteration surgery is challenging
and can be very difficult due to the anatomical con-
fines of the bony pelvis and undefined surgical planes
from previous surgery or radiotherapy. Therefore,
such surgery is best done in specialized units.
The major series on surgery for LRRC in the past
20 years have reported overall 5-year survival rates
of 20–35 per cent.9,10,15,16,19 Data have shown that
exenteration surgery for LRRC can be performed
successfully with minimal mortality rates of 0–1
per cent.9,10,15,17 Furthermore, the extent of resec-
tion does not influence long-term survival.9,10,16,18
Surgery is the only modality that offers a chance
for long-term survival.9,10,15,19 Surgery does entail a
significant morbidity rate, but unrelated to the ex-
tent of resection.10 Morbidity rates from the recent
larger series are in the range 24–27 per cent.9,10,17
08/02/13 5:34 PM
 204  Assessment and management of recurrence
Bedrosian and colleagues suggest there is a bio-
logical variance between truly locally recurrent rec-
tal cancers and those that disseminate.15 This is sup-
ported by Wong and colleagues,20 but their analysis
was of colonic cancer. They concluded there are
two types of colonic cancers – locally active cancers
and cancers that have the tendency to metastasize.
Approximately 50 per cent of patients with local
pelvic recurrence do not have distant disease.21–23
Approximately two-thirds of this group can have a
curative surgical resection.10,14 These patients with
R0 pathology have 5-year survival rates of up to 49
per cent.10
The encouraging results of the more recent larger
series have fuelled the growing interest in surgical
resection for LRRC. This chapter defines and out-
lines the principles of assessment and surgical man-
agement of LRRC.
Presentation
Patients usually present with symptoms that reflect
the location of the recurrence.4,5,9 Symptoms in-
clude pelvic pain or referred pain, per rectal bleed-
ing and discharge, altered bowel habit and tenes-
mus; the most common is pain. Pain is caused by
local invasion of bone, the sacrum or pelvic side-
wall, or invasion into nerves, sacral nerve roots or
the sciatic nerve. Referred pain is in the distribution
of the involved sciatic nerve.
Asymptomatic patients are identified during rou-
tine colorectal cancer follow-up. Pelvic recurrences
may be detected during a digital rectal or vaginal
examination, colonoscopy or routine follow-up
computed tomography (CT) scan. A rising trend in
the carcinoembryonic antigen (CEA) should raise
the suspicion for recurrence in an asymptomatic
patient. This will initiate a cascade of investigations.
In a Cochrane review published in 2007, intensive
follow-up was found to be associated with improved
overall survival and earlier detection of recurrence,
suggesting that earlier detection may permit earlier
intervention leading to improved survival.24
Locally recurrent rectal cancer most commonly
recurs within the first 2–3 years after seemingly
curative resection.5,24 In a study by Wanebo and
colleagues, 28 per cent of patients presented with-
in 1 year after initial resection, while 36 per cent,
17 per cent and 15 per cent presented within 2 years,
HEBK001-C13_p203-221.indd 204
3 years and more than 3 years after initial surgery,
respectively.25 In a study by Heriot and colleagues,
time to recurrence was within a year in 28 per cent
of patients, in the second year in 29.5 per cent, in
the third year in 18 per cent and more than 3 years
after surgery in 24.5 per cent.10 In a large series from
the Mayo Clinic, 19 per cent, 26 per cent and 55 per
cent of patients presented within 1 year, 2 years and
after 2 years, respectively.9
Preoperative assessment and
preparation for surgery
All patients should have localized pelvic disease
confirmed by CT, magnetic resonance imaging
(MRI) and positron-emission tomography (PET)
before consideration of proceeding to surgery. Al-
though CT and PET imaging give vital information
regarding metastatic disease, MRI is most useful
in determining resectability and meticulous plan-
ning of the surgical approach. The current con-
sensus amongst the institutions performing pelvic
exenteration is to perform all three scans. With
the emergence and popularity of PET/CT, routine
standard CT scans can be avoided.
Less than 5 per cent of pelvic exenterations are
said to be irresectable at the time of surgery after
preoperative clinical and radiological assessment
including CT, MRI and PET.4
Clinical Assessment
Clinical assessment with an examination under
general anaesthetic is frequently performed before
pelvic exenteration. Examination without anaes-
thesia is invariably painful and unpleasant for the
patient. Tumour fixation and involvement of other
pelvic organs can be assessed. Additionally, biopsy
for tissue confirmation of recurrence, cystoscopy
and transanal ultrasound can all be performed
without causing pain to the patient.
Carcinogenic Embryonic Antigen
A rise in CEA prompts investigation for recurrence,
although it does not always rise with recurrence and
does not help to determine tumour resectability.26
08/02/13 5:34 PM
 Preoperative assessment and preparation for surgery  205
The specificity is up to 84 per cent, but sensitivity
is poor, at 59 per cent. The CEA level may provide
prognostic information, as some studies have dem-
onstrated that an elevated CEA is associated with
worse survival in recurrent pelvic disease.27,28
Colonoscopy
Colonoscopy should be performed to biopsy intra-
luminal recurrent tumour and exclude synchronous
colonic malignancies. Anastomotic recurrences are
generally discovered during postoperative surveil-
lance colonoscopies.
Computed Tomography
A CT scan of the chest, abdomen and pelvis is per-
formed routinely and is the first step for staging re-
currence before pelvic exenteration. In recent years,
PET scans have become more precise in locating
the recurrence, and the incorporation of CT in the
form of a PET/CT scan is optimal.
Pelvic Magnetic Resonance Imaging
Magnetic resonance imaging is an essential and
optimal mechanism for locoregional staging of the
recurrence and for planning pelvic exenteration.
An MRI scan is the best imaging modality avail-
able for soft tissue, lymph nodes and tumour defi-
nition. The images are superior to those of a CT
scan. The MRI scan provides accurate assessment
of the tumour, and extent of involvement of adja-
cent pelvic viscera, including invasion into bone,
nerve, vessels and ligaments. A significant disad-
vantage of MRI is the difficulty in distinguishing
between recurrent disease and post-radiotherapy
or post-surgical fibrosis and inflammation;29 the
addition of a PET scan, or even better a PET/CT
scan, complements MRI to help distinguish be-
tween the two.30–32 In an early study by Popovic
and colleagues, MRI was found to have an accu-
racy of 83 per cent in determining patients’ eli-
gibility for pelvic exenteration.33 The accuracy of
MRI will continue to improve with future devel-
opments in technology and the implementation of
thinner MRI sections.34
HEBK001-C13_p203-221.indd 205
Positron-Emission Tomography
Positron-emission tomography scans have been
shown to be highly accurate in the detection of dis-
seminated disease and have been shown to alter the
management of 20–40 per cent of patients by demon-
strating distant disease otherwise undetected on con-
ventional imaging.26,35 One of the major limitations of
CT and PET scans, however, is that peritoneal disease
may go undetected until the time of surgery. Further-
more, PET scans are less accurate for the mucinous
variant of adenocarcinoma and can be false positive
with any inflammatory condition.
Chemotherapy and Radiotherapy
Before surgery, patients not previously exposed to
radiotherapy would usually receive long-course ra-
diotherapy with a chemosensitizer. In an era where
radiotherapy is used increasingly, most patients with
recurrent rectal cancer are likely to have already been
exposed to radiotherapy; moreover, most patients
will have received the maximum permissible dose. To
circumvent the issue of tissue toxicity, intraoperative
radiotherapy (IORT) has been developed with the
ability to deliver a boost of up to 10 Gy directly to the
tumour bed, which has a biological activity of two-
to threefold that of external-beam radiotherapy.36
Intraoperative radiotherapy can be performed as
either intraoperative electron-beam radiotherapy
or intraoperative high-dose-rate brachytherapy.37,38
Combined with tissue shielding, toxicity to the
surrounding tissue can be effectively minimized;
therefore, IORT is feasible in previously irradiated
patients.10,37–40 This has been advocated for R2 resec-
tions at the time of surgery, but unfortunately it is
not readily available in all units. Although some au-
thors have demonstrated significant survival benefit
with IORT, it does not replace inadequate surgery.40,41
Intraoperative radiotherapy becomes less significant
with the advancements in pelvic exenteration, in
particular with the encouraging results of increasing
proportion of complete tumour clearance rates (R0)
for laterally recurrent cancers using the technique of
en-bloc resection of the internal iliac vasculature and
bone.42 Intraoperative radiotherapy will therefore be
beneficial for the scenario where resection was pro-
posed as potentially complete but intraoperatively
inadvertent dissection through the tumour occurs.10
08/02/13 5:34 PM
 206  Assessment and management of recurrence
Relative and absolute
contraindications for pelvic
exenteration
Many authors have reported absolute and relative
contraindications for pelvic exenteration (Table 13.1).
Pelvic exenteration surgery has advanced considerably
over the past decade, pushing the boundaries and re-
defining the extent of surgical techniques. As a con-
sequence, the lists of contraindications are obsolete
and continuously being redefined, and the number of
absolute contraindications is diminishing. Nonethe-
less, some of the absolute contraindications have re-
mained; these include patient performance, multiple
distant metastases, including para-aortic lymph node
disease, and sacral recurrences necessitating resection
of the whole S1 vertebral body.
Indications for curative pelvic exenteration surgery
depend on patient factors and the extent of disease.
Due to the high morbidity rates and extent of physi-
ological insult induced during and after pelvic ex-
enterations, the patient must be relatively fit (with an
American Society of Anesthesiologists (ASA) score of
3 or less) and have tumour recurrence localized to the
pelvis without distant metastases, unless distant me-
tastases are resectable with curative intent. Pelvic ex-
enteration with curative intent has been performed in
patients with limited visceral metastases with accept-
Table 13.1. Absolute and relative contraindications for pelvic exenteration.
Study Absolute Contraindications
Boyle et al.4
Encasement of external iliac vessels
Extension of tumour through the sciatic notch
Presence of lower limb oedema from lymphatic or venous
obstruction
Poor performance status
Pawlik et al. 43
Distant metastases
Involvement of common or external iliac vessels
Para-aortic lymph node metastases
Involvement of sacrum above S1
Tumour extension through sciatic foramen
Pelvic side-wall involvement
Ogunbiyi et al.6 Tumour invading above S2
Involvement of pelvic side-wall or pelvic nerves
Involvement of ureters or presence of hydronephrosis on
imaging
HEBK001-C13_p203-221.indd 206
able results.44 They include patients with unilateral liver
metastases or solitary pulmonary recurrence. None-
theless, these represent only a small group of highly
selected patients.
Lateral pelvic recurrences are no longer an abso-
lute contraindication, as reported by some encour-
aging results.42 Extended resection laterally is pos-
sible, and extended lateral resections with lateral
pelvic bone and ligament resections have been per-
formed. This provides access to, and the ability to
resect, some recurrences that extend to and through
the greater sciatic foramen. Lateral nerve involve-
ment is not an absolute contraindication, because
as long as the lumbosacral nerve and S1 nerve roots
are preserved adequate lower limb motor function
can be preserved.
External iliac vessel encasement is not an absolute
contraindication if the vessel can be reconstructed
after obtaining an R0 resection. Lower limb oedema
is also not an absolute contraindication.
Similarly, ureteric involvement is not a con-
traindication unless curative resection was deemed
impossible preoperatively. Preoperative decisions
and preparations for unilateral nephrectomy, ure-
terectomy and reimplantation or, if necessary, radi-
cal cystectomy and conduit need to be planned.
Essentially, if there is inoperable metastatic dis-
ease or an oncological resection is not possible with
Relative Contraindications
Distant metastases
Primary stage IV disease
Extensive pelvic side-wall involvement
Inability to achieve R0 resection
Sacral invasion above S2/3
Ureteral obstruction
Significant medical comorbidity
Poor performance status/inability to care for stomas
Distant metastases
Diffuse intra-abdominal nodal metastases
08/02/13 5:34 PM

a clear pelvic margin, then this would be the major
contraindication for pelvic exenteration.
Metastatic disease no longer automatically pre-
cludes patients from pelvic exenteration. There is
some evidence to suggest that patients with limited
and resectable metastasis can survive, and some even
beyond 5 years. 41,44–49 Nevertheless, these patients are a
highly select group, and pelvic exenteration was per-
formed after considerable deliberation and debate.
Similar to the situation in primary colorectal cancers,
there is no consensus on the optimal sequence of sur-
gery. Some surgeons advocate staged procedures while
others perform synchronous resections.41,44–50
Rarely, pelvic exenteration can be performed for
palliation. These cases include uncontrollable ma-
lignant masses with small and large bowel to vesi-
cal, vaginal and or cutaneous fistulae, unmanageable
malignant cutaneous and vaginal wounds, and in-
tractable sciatic nerve or pelvic soft tissue pain. In
addition to the indications and contraindications
for surgery, quality-of-life implications and patient
choice are significant factors to be considered before
informed consent.
Multidisciplinary team
planning and management
All decisions regarding the management of patients
considered for pelvic exenteration surgery should
be made in a multidisciplinary setting with all in-
volved relevant medical and surgical specialties. The
multidisciplinary team meetings should optimally
involve not only the various surgical, perioperative
anaesthesiology and oncological specialties but also
allied health specialists, including stoma therapy,
rehabilitation, nutrition and psycho-oncology sup-
port and expertise.
Classification
Several classification systems have been proposed.
Anatomical classifications are most commonly
used, although none is universally accepted. Suzuki
and colleagues from the Mayo Clinic published a
classification system based on symptoms and degree
of fixation (Table 13.2).51 Although this study did
not reveal any association between survival, symp-
tomatic recurrence and points of fixation, a sub-
HEBK001-C13_p203-221.indd 207
Anatomy of exenteration surgery  207
sequent larger study by Hahnloser and colleagues
from the Mayo Clinic found recurrence with pain
and increased fixity of the tumour to be associated
with greater operative challenges, difficulty with
delivering intraoperative radiotherapy and sig-
nificantly reduced survival.9 In 1999, Wanebo and
colleagues proposed a classification system based
on the Union for International Cancer Control
(UICC) TNM staging system (Table 13.2), where
the tumour recurrence stage increased depending
on the depth of invasion through the bowel wall
and beyond.25
The Memorial Sloan Kettering group, Leeds
group and Yamada and colleagues described clas-
sification systems based on the anatomical location
of local recurrence.
In the classification system by the Memorial
Sloan Kettering group, recurrence was classified as
central including anastomotic, perirectal and mes-
orectal recurrences, anterior, posterior or lateral.52
The Leeds group classified recurrence as central,
sacral, side-wall or composite, depending on the
structures involved (Table 13.2).4 Yamada and col-
leagues classified recurrence into localized (cen-
tral), lateral or sacral recurrences;28 in their study,
lateral recurrences were associated with a signifi-
cantly lower overall survival.
Classification of LRRC is important for com-
parative and management purposes, but the sites
or number of points of fixation is significantly im-
portant for determining clear margins and therefore
prognosis.
Anatomy of exenteration
surgery
Patients who present with localized recurrent pelvic
cancer are a heterogeneous group in terms of the
involved pelvic structures; as such, the definition of
extent of resection is debatable. As a result, there is
no standard defined surgical procedure performed,
but instead the type of operation is dependent on
the site of the tumour, the size of the tumour and
the number of organs involved. This means that
a number of different pelvic organs, vasculature,
muscles, ligaments, nerves and pelvic bone compo-
nents are excised. To understand the operative ap-
proaches, the pelvis can be divided into four main
compartments (Figure 13.1):
08/02/13 5:34 PM
 208  Assessment and management of recurrence

Table 13.2. Comparison between different classification systems.

Study Description
Suzuki et al.51 Symptoms
  S0 Asymptomatic
  S1 Symptomatic without pain
  S2 Symptomatic with pain
Degree of fixation
 F0 Not fixed
 F1 Single-point fixation
 F2 Two-point fixation
 F3 Three or more points of fixation
Wanebo et al. 25
TR1 Local recurrence at local excision site/anastomosis with invasion of submucosa
TR2 Local recurrence at local excision site/anastomosis with full invasion of muscularis propria
TR3 Local recurrence at anastomosis beyond muscularis with involvement of perirectal soft tissue
TR4 Local/focally extensive invasion of rectum or other organs – anteriorly into vagina, uterus, prostate, bladder or
  seminal vesicles, posteriorly into presacral tissue (tethered, not fixed)
TR5 Extensive invasion of pelvis – bony/ligamentous pelvis
Guillem et al.52 Central – including mesorectal, anastomotic, perirectal recurrences or perineal recurrences after
  abdominoperineal resection
Anterior – uterine, vaginal, prostate, bladder, seminal vesicles
Posterior – sacrum and presacral fascia
Lateral – side-wall soft tissue or bony pelvis
Boyle et al.4 Central – tumour confined to pelvic organs without involvement or invasion into bone
Sacral – tumour in presacral space and abuts or invades sacrum
Side-wall – tumour involving structures on pelvic side-wall, including greater sciatic foramen, sciatic nerve,
  through to piriformis and gluteal region
Composite – simultaneous involvement of sacrum and pelvic side-wall
Yamada et al.28 Localized – localized to adjacent pelvic organs and connective tissue
Sacral invasive – recurrent tumour that invades lower sacrum (S3–5), coccyx and periosteum
Laterally invasive – tumour involving sciatic nerve, greater sciatic foramina, lateral pelvic wall or upper sacrum (S1–2)

l Anterior compartment: consists of the bladder, nerves S1–S4, pelvic bone (sacrum and coccyx),
prostate, seminal vesicles, vas deferens, urethra, anterior sacrococcygeal ligament, medial sacrotu-
urogenital diaphragm, dorsal vein complex, ob- berous and sacrospinous ligaments.
turator internus and externus muscle, anterior l Lateral compartment: consists of the pelvic

half of the vagina, anterior pelvic floor muscle
(pubococcygeus and puborectalis part of the
levator ani), and pelvic bone (pubic symphysis,
superior and inferior pubic rami).
l Axial compartment: consists of the posterior half
of the vagina, uterus, ovaries, fallopian tubes,
broad ligament, round ligament of uterus, rectum,
pelvic floor muscle (iliococcygeus part of levator
ani), lower sacrum (S4 down) and coccyx.
l Posterior compartment: consists of the rectum, pel-
vic floor (coccygeus muscle), internal iliac vessel
branches and tributaries, piriformis muscle, sacral
side-wall structures, ureter, internal iliac vessels,
external iliac vessels, piriformis and obturator
internus muscle around the ischial spine, coccy-
geus muscle, lateral sacrotuberous and sacros-
pinous ligaments attached to ischium, ischium
including tuberosity and spine, lumbosacral
trunk and sciatic nerve distal to ischial spine
and obturator nerves and vessels.
In general, the four compartments can be best
understood by their central points as there is some
degree of overlap of their peripheries. The central

HEBK001-C13_p203-221.indd 208 08/02/13 5:34 PM


Figure 13.1. Anatomical compartments of the pelvis.
(Reproduced from O’Connell R, Madoff R, Solomon M
(eds). Operative Surgery of the Colon, Rectum and Anus,
6th edn. London, Hodder Arnold, 2013, with permission.)
axis of the anterior compartment is the urethra, for
the axial compartment it is the tip of the coccyx,
for the posterior compartment it is the third sacral
vertebra, and for the lateral compartment it is the
ischial spine.
In view of the heterogeneity in the types of re-
section, these are best defined as either partial or
complete pelvic exenterations. A complete pelvic
exenteration is defined as removal of the primary or
recurrent tumour (with or without attached bone)
with all remaining pelvic viscera – that is, all four
anatomical components of the pelvis. Partial pelvic
exenteration is defined as removal of the primary or
recurrent tumour (with or without attached bone)
with en-bloc resection of up to three anatomical
components of the pelvis.
Pelvic exenteration always involves an abdominal
approach, usually with a perineal completion phase
that can be done in the lithotomy or prone position.
The anterior, axial and lateral compartments are
best done through an abdominal combined with a
perineal lithotomy approach. Posteriorly, resection
of the sacrum from the fourth sacral vertebra (S4)
down and the sacrospinous ligaments allows radical
excision of posterior pelvic floor that is approached
from the abdominal side and is often better visual-
ized than in the prone position.
Involvement of the third sacral vertebrae (S3),
and above, because of the nature of the sacroiliac
joint attachment, requires a prone approach un-
less resection involves only the anterior cortex of
the midline bones up to the fifth lumbar vertebra
HEBK001-C13_p203-221.indd 209
Surgical technique  209
(L5) and upper sacrum, as this can be done ab-
dominally. Lateral higher sacrum and full verte-
bral excision of S2 and S3 require the posterior
prone approach.
Depending on the number and type of pelvic
organs involved in the malignant process, the pro-
cedure requires a multidisciplinary team of highly
skilled consultant surgeons from the surgical spe-
cialties of colorectal surgery, vascular surgery, urol-
ogy, orthopaedics, and plastics and reconstructive
surgery. At our institution, colorectal surgeons pre-
dominantly perform the surgery, with other sur-
gical disciplines being involved at the appropriate
time. Specialist anaesthetist and experienced thea-
tre nursing staff are also required, as the procedure
can take up to 8 to 20 hours.
Surgical technique
The aim of surgery is to achieve an R0 resection.
This is the principle predictor of long-term sur-
vival. The resection depends on the location of the
recurrence in the pelvis and whether the surround-
ing organs and structures are involved. The pelvis is
bounded by bone and, if necessary, the bone is re-
sected as part of the en-bloc specimen. This should
be performed only if stability of the pelvis can be
preserved.
The planes for exenteration are ill-defined due to
the previous rectal dissection, quite commonly having
been a total mesorectal excision (TME). There will in-
evitably be fibrotic tissue from previous surgery and
radiotherapy, which can mimic malignancy.
The surgeon must be aware of the necessity to
obtain clear margins on the resected specimen and
must dissect laterally to obtain wider circumfer-
ential margins. Involved lateral structures (ureter,
nerve, vessels) are resected, often with bony mar-
gins if needed.
The pathologist should be aware of the anatomi-
cal differences between primary resection and pelvic
exenteration. Circumferential, proximal and distal
margins in numerical values become less significant;
instead, whether each margin is free of malignancy is
of primary importance (i.e. R0, R1, or R2).
The principles of surgical oncology are essential
for curative intent. To achieve tumour-free resec-
tion margins (R0 resection), resection must be en
bloc. Moore and colleagues observed that central or
08/02/13 5:34 PM
 210  Assessment and management of recurrence

anterior pelvic recurrences were more likely to have Until recently, a lateral pelvic wall recurrence reflected
R0 resections than other locations, especially lateral a negative prognostic factor with consistently poor
recurrences.53 Other institutions have shown that survival rates. Austin and Solomon reported R0 rates
lateral pelvic side-wall recurrence is a significant as high as 53 per cent for lateral recurrences. Pelvic ex-
negative prognostic indicator for survival.10,28 enteration included the excision of the lateral vascu-
Heriot and colleagues classified pelvic exenteration lature (internal iliac vessels) to achieve clear margins.
into radical and extended radical excisions.10 Radical The overall survival rate after local recurrence surgery
resection is confined to the recurrence involving the was 69 per cent and disease-free survival was 72 per
pelvis and neorectum. Radical resections can be ap- cent at a mean follow-up of 19 months.42
propriate for central recurrences. Predominantly, a
radical resection requires an abdominoperineal exci-
sion but, a redo anterior resection or Hartmann’s pro- Classification of Operations
cedure have been performed for selected cases.4,10,17,54
Extended radical resection involves at least one adja- The magnitude and type of exenteration can be
cent pelvic organ (bladder, prostate, seminal vesicles, broadly described in five approaches (the letters in the
uterus, ovaries, vagina, ureter, iliac vessels, small bowel, list below reflect the planes in Figures 13.2–13.5):
sacrum). The subgroups of anterior (bladder, prostate,
A anterior plane for total pelvic exenteration or
seminal vesicles, uterus, vagina, ovaries), posterior
anterior pelvic exenteration;
(sacrum), anteroposterior, and lateral (internal iliac
B anterior plane for axial pelvic exenteration with
vessels, ureter) extended radical resection are defined
subtotal vaginectomy; in male patients, this
by the organs and structures resected.
includes B and the perineal part of A;
Urinary tract involvement is common and can re-
C anterior plane for axial pelvic exenteration with
quire complex urological interventions. Brunschwig
posterior vaginectomy (in female patients only);
described the first pelvic exenteration with ureteral
D posterior plane for total pelvic exenteration or
diversion into the colon for locally advanced pelvic
axial pelvic exenteration;
cancer in 1948.55
E posterior plane for abdominosacral exenteration.
Wanebo, a pioneer and advocate for surgery for
LRRC, has published extensively on abdominosacral
resections.3,25,56,57 He describes a two-stage procedure.
The first stage is performed in the modified Lloyd Dav-
ies position; the second stage, 2 days later, is done in the
prone position. An extensive nodal dissection is per-
formed from the distal aorta to the pelvic side-walls.
The current contentious issues revolve around
the traditional anatomical limits of resecting with a
clear margin, such as involvement of any bone other E

than S2 down, and major vascular or lumbosacral,

sciatic or femoral nerve involvement. This is in con-
trast to previous issues, when consideration of any
surgical resection for recurrence was contentious. An
understanding of outcomes both with and without
exenteration, including long-term survival data, op-
erative morbidity and mortality, length of hospital
stay, length of rehabilitation and quality of life, must
be considered and discussed in detail. Historically, the
mean hospital stay was 5 weeks,16 but now the average D CB A
is closer to 3 weeks, with recovery taking 3–6 months
Figure 13.2. Resection planes in pelvic exenteration (female).
before a stable quality of life is achieved. Reproduced from O’Connell R, Madoff R, Solomon M
Surgery for LRRC has advanced significantly in (eds). Operative Surgery of the Colon, Rectum and Anus,
the past decade. New boundaries have been defined. 6th edn. London, Hodder Arnold, 2013, with permission.

HEBK001-C13_p203-221.indd 210 08/02/13 5:34 PM


C
B A
Figure 13.3. Resection planes in pelvic exenteration (male).
Reproduced from O’Connell R, Madoff R, Solomon M
(eds). Operative Surgery of the Colon, Rectum and Anus,
6th edn. London, Hodder Arnold, 2013, with permission.
In broad principles the resection margin for the
involved compartment of the pelvis is the soft tissue/
bone attachment or en-bloc excision of the involved
bone. Attempting to obtain soft tissue margins of
Figure 13.4. Resection planes in pelvic exenteration (axial
view, female). Reproduced from O’Connell R, Madoff R,
Solomon M (eds). Operative Surgery of the Colon, Rectum
and Anus, 6th edn. London, Hodder Arnold, 2013, with
permission.
HEBK001-C13_p203-221.indd 211
Surgical technique  211
A R
Figure 13.5. Lateral pelvic resection. Reproduced from
O’Connell R, Madoff R, Solomon M (eds). Operative
Surgery of the Colon, Rectum and Anus, 6th edn.
London, Hodder Arnold, 2013, with permission.
involved compartments will result in unacceptably
high rates of margin positivity (R1 and R2).
Pelvic Exenteration: Abdominal Phase
Perioperative preparations
Stoma sites are marked. If necessary, the elliptical cu-
taneous incision for the vertical rectus myocutane-
ous flap is marked with a surgical skin marker. If the
patient already has a colostomy, this is covered with
a swab and impervious plastic dressing so that it is
not removed during the lengthy procedure. Bowel
preparation is usually advisable, as the long dura-
tion of the exenteration and previous radiotherapy
may contribute to a common requirement to repair
damaged bowel. Bowel preparation can be omitted
in patients with pre-existing stomas, but the colon
should be prepared if a colostomy is to be converted
into a colonic conduit.
The insertion of ureteric stents before the
laparotomy is especially useful for central exentera-
tions where the bladder is to be preserved but is
worth considering in all patients.
08/02/13 5:34 PM
 212  Assessment and management of recurrence
Positioning
The patient is placed directly on a gel mattress to secure
their position and prevent unexpected slippage dur-
ing steep Trendelenburg positioning. The abdominal
phase of pelvic exenteration is performed in the modi-
fied Lloyd Davies position, with both arms secured at
the patient’s side. The perineal phase can also be per-
formed in the modified Lloyd Davies or prone posi-
tion. Sacrectomy above S3 is performed in the prone
position. Partial anterior sacrectomy, or a distal sac-
rectomy below S3, can be performed from a transab-
dominal approach. The anus, if present, is sutured, pre-
venting soiling during the operation. The vagina is also
included in the skin preparation. When draping the
patient, exposure should include the groin and thigh in
preparation for vein harvest if vascular reconstruction
is necessary with an interposition graft or patch.
Laparotomy
Despite resectability having been predicted preopera-
tively by CT, MRI and PET scans in a multidiscipli-
nary setting, the initial role of surgery is to exclude
metastatic peritoneal disease that may not have been
detected by preoperative testing. A thorough laparot-
omy and adhesiolysis is performed meticulously and
cautiously to prevent enterotomies in radiotherapy-
damaged small bowel. If negative for small-volume
missed peritoneal disease, then the planned exentera-
tion surgery begins. Of note, lateral pelvic side-wall
involvement and bone fixity are not contraindications
for pelvic exenteration surgery, although these fea-
tures are best assessed by MRI preoperatively rather
than by palpation at laparotomy.
Any nodule suspicious for peritoneal metastasis
or hard tissue suspicious for carcinoma encoun-
tered during the pelvic dissection should be sent for
frozen section. Confirmation of malignancy may
change the course of the operation.
Preparing the pelvis
Adhesiolysis is necessary for a re-laparotomy. The
small bowel is mobilized out of the pelvis; the small
bowel is often adherent to the tumour in recurrent
disease, however, and requires en-bloc resection.
The involved segments of small bowel are discon-
nected from the rest of the small bowel with a linear
gastrointestinal stapling and cutting device. The ap-
pendix, if still in situ, is usually removed; this is to
avoid potential future difficulty with abdominal ac-
cess after exenteration with combinations of stomas,
HEBK001-C13_p203-221.indd 212
abdominal wall mesh reconstruction, and surgery
often involving myocutaneous flaps. An open ap-
pendicectomy post exenteration has the difficulty of
access as well as the potential risk of damaging the
inferior epigastric vessels which will compromise.
The ureters are identified, mobilized with ad-
equate connective tissue to avoid damage to the
ureteric blood supply, and protected with vessel
loops. The ureters may have been displaced, usu-
ally laterally, due to previous pelvic dissection. The
gonadal vessels are preserved if possible in male pa-
tients, but they are ligated in female patients during
radical hysterectomy. Preservation of the abdomi-
nal portion of the gonadal vessels is important for
the arterial blood supply of the ureters. The pelvic
portions of the ureters are transected when an ileal
conduit is planned and performed.
Lateral pelvic wall lymph node dissection is rou-
tine with pelvic exenteration. The lymphadenecto-
my includes the nodes of the common iliac bifurca-
tion, internal iliac chain and obturator nodes.
In pelvic exenteration with sacrectomy, a metal-
lic pin is inserted into the sacrum above the level of
sacral involvement. An image intensifier can locate
this pin in the prone position, thus ensuring the pre-
cision of the level of sacral transection.
Perineal Phase
The perineal phase is performed via a wide lithoto-
my exposure, in the prone position or sequentially
after prior lithotomy to widely resect the anterior
compartment and then in the prone position for
the posterior compartment.
The prone phase is for the sacrectomy, if needed.
The sacrectomy is the final step for the complete
resection of the recurrence. The en-bloc specimen
with the transected sacrum is delivered and the de-
fect is closed, commonly with a myocutaneous ver-
tical rectus abdominus muscle (VRAM) flap.
Different Surgical Approaches to
Pelvic Exenteration
Pelvic exenteration comprises a heterogeneous
group of surgical operations commonly involving a
combination of the different subcategories. This is
to achieve an R0 resection, since resection margin is
08/02/13 5:34 PM

the single most significant prognostic factor deter-
mining long-term survival.
The different surgical approaches for pelvic ex-
enteration have been classified into subgroups ac-
cording to the anatomical classification of LRRC.
Overlap between the groups is common, and inevi-
table in most cases, due to the nature of LRRC.
Central (axial) pelvic exenteration
Central or axial recurrences represent anastomotic,
perirectal and mesorectal recurrences without lateral
pelvic wall involvement. This is surgery for central
LRRC using the Memorial Sloan Kettering definition
(see Table 13.2). Central recurrences can occur at the
anastomosis without extraluminal spread. In such a
case, redo low anterior resection (including the pre-
vious anastomosis) or abdominoperineal excision of
the rectum can be performed without resection of any
other structures (see Figure 13.3, planes D and C plus
pelvic part of A). Heriot and colleagues reported that
63 of 160 patients (39 per cent) in their series had cen-
tral recurrence.10 Unfortunately, redo anterior resec-
tion is uncommon and reported at 5–10 per cent.9,10
Abdominoperineal excision is more common and in
the region of 26 per cent.10 The usual scenario is in-
volvement of other organs and structures, and thus an
extended resection is required.
In female patients, axial pelvic exenteration in-
volves en-bloc resection of the recurrence and hys-
terectomy with vaginectomy. The bladder and ante-
rior wall of the vagina can usually be preserved (see
Figure 13.2, planes D and C) as the uterus and pos-
terior wall of the vagina provide protection. If these
organs are involved, then total pelvic exenteration is
performed (see Figure 13.2, planes D and A).
In patients in whom the dome of the bladder is
involved, wedge resection with primary closure is
performed. If a unilateral distal ureter is involved,
then resection of the ureter with reimplantation
with a Boari flap or psoas hitch can be used.
The TME plane no longer exists and therefore
obtaining a clear circumferential margin becomes
a great challenge. Additionally, the induration af-
ter radiotherapy usually adds considerably to the
difficulty.
Total pelvic exenteration
Total pelvic exenteration is an extension of central
pelvic exenteration that includes the anterior com-
partment organs, namely the bladder and adjacent
HEBK001-C13_p203-221.indd 213
Surgical technique  213
reproductive organs – that is, surgery for anterior
and central LRRC (see Table 13.2). Additionally,
lateral pelvic exenteration may also be required as
part of total pelvic exenteration (see Lateral pelvic
exenteration below).
Total pelvic exenteration in male patients involves
en-bloc resection of the anterior compartment or-
gans (bladder, prostate and seminal vesicles), the
rectum and previous anterior resection anastomo-
sis with the recurrence (see Figure 13.3, planes D
and A). This incorporates an abdominoperineal ex-
cision with radical cystoprostatectomy and forma-
tion of a urostomy.
In female patients, the more extensive recur-
rence that invades beyond the protective barrier
of the uterus and vagina, with involvement of the
trigone of the bladder, warrants radical cystectomy
and formation of a urostomy with total abdominal
hysterectomy, bilateral salpingo-oopherectomy and
abdominoperineal excision.
The posterior plane (plane D) is the same for
central pelvic exenteration and total pelvic ex-
enteration. There is no anatomical plane but rather
ill-defined fibrotic tissue as a result of the previ-
ous rectal resection. Hence, the exenteration dis-
section plane may include the presacral fascia to
achieve clear margins. If there is any doubt that
there is no posterior plane and the sacrum may be
involved, then there should be no hesitation to pro-
ceed to abdominosacral exenteration. At this stage,
a frozen section of ‘suspicious presacral tissue for
carcinoma’ should be analysed for histological con-
firmation. This scenario occurs when the tumour
has progressed despite no previous evidence of sac-
ral invasion on MRI scan and post-radiotherapy or
the presacral tissue has been interpreted at imaging
as ‘postoperative scar tissue’.
Abdominosacral exenteration
Abdominosacral exenteration is a total exentera-
tion with the addition of sacrectomy. This is usually
necessary in patients with extensive posterior LRRC
(see Table 13.2).
Sacrectomy can be performed at the S1/S2 junc-
tion without pelvic instability. After completion
of the abdominal phase with reconstruction and
abdominal wall closure, the patient is transferred
to the prone jack-knife position for sacrectomy.
During the abdominal phase, a metallic pin is in-
serted into the sacrum at the level of the proposed
08/02/13 5:34 PM
 214  Assessment and management of recurrence
transection. With the aid of an image intensifier,
the pin is located while the patient is in the prone
jack-knife position to confirm the precise level of
the sacrectomy.
Sacrectomy does not have to be a complete resec-
tion. In selected patients an anterior cortical or partial
resection of the sacrum can be performed. This is best
performed in the abdominal phase. Additionally, dis-
tal sacrectomy, at the S4/S5 junction and below, can be
performed during the abdominal phase, thus avoiding
the necessity for the prone position.
Before sacrectomy, especially proximal sacrectomy
(S3/S4 junction and above), internal iliac vessel liga-
ture, referred to as ‘pelvic devascularization’, is recom-
mended to minimize pelvic haemorrhage. Ligation of
the internal iliac vessels inherently involves the dissec-
tion of the lateral pelvic lymph nodes, starting from
the common iliac lymph chain and down to the obtu-
rator lymph nodes. Bleeding from inadvertent injury
of the internal iliac vessels, especially the veins, can be
profuse and has led to uncontrollable and fatal haem-
orrhage.42 Arterial ligation distal to the first branch of
the internal iliac artery is preferred to promote skin
and muscle flap healing.2 The use of vessel loops of
different colours helps to isolate the different struc-
tures and for proximal and distal vascular control.
During sacrectomy, especially proximal sacral
transection, sacral nerves are sacrificed. The liga-
tion of the proximal sacral nerves (S1, S2) leads to
significant morbidity. In contrast, the lower sacral
nerves are relatively less important and adequate
limb function is still achievable.
The lumbosacral and S1 nerve root must be pre-
served to maintain motor function of the lower limb
on that side. Gait without a foot-drop is preserved if
the majority of the sciatic nerve is preserved.
Ligation of S2 and lower sacral nerves will result in
an atonic bladder. The bladder in a patient with recur-
rent rectal cancer has commonly been damaged pre-
viously by radiotherapy and prior surgery. Therefore,
sacrectomy above S4 may require a radical cystectomy,
even if there is no invasion into the bladder, prostate
or seminal vesicles. The alternatives of self-catheteri-
zation and permanent suprapubic urinary catheteri-
zation should also be considered.
Lateral pelvic exenteration
Previously, lateral side-wall recurrence with ureter-
ic, neural or pelvic vascular involvement were con-
traindications for pelvic exenteration.4,9,10,15–17,22,28,51,57
HEBK001-C13_p203-221.indd 214
These limitations have been redefined. Over the past
decade, the Royal Prince Alfred Group in Sydney,
Australia has implemented a surgical approach for
lateral pelvic wall recurrences with encouraging R0
resection rates and survival.42
Lateral pelvic exenteration is performed for lat-
eral LRRC (see Table 13.2) and may be necessary in
total pelvic exenteration. Internal iliac vessel liga-
tion and resection is essential for lateral pelvic ex-
enteration to ensure an R0 resection margin.
The first step is to mobilize the pelvic ureters
laterally and then ligate the internal iliac artery
bilaterally. It is preferable, if possible, to ligate dis-
tal to the first branch of the internal iliac artery to
maximize healing of the skin and muscles in the
buttock region. The distal branches of the internal
iliac vessels usually need to be ligated individually.
Next, the venous system is ligated and resected en
bloc with lateral tumours. This exposes the lum-
bosacral trunk and sacral nerve roots (S1, S2, S3) as
they converge to form the sciatic nerve at the ischial
spine. The piriformis muscle lies deep to the nerves.
Lateral pelvic recurrences may involve sacral
nerve roots and the sciatic nerve. If necessary, the
sciatic nerve can be sacrificed to obtain an R0 resec-
tion, but at the cost of an altered gait and requiring
an orthotic aid for the ankle joint.
The ischial spine can be resected to gain maxi-
mal lateral exposure and reveal the sciatic nerve as
it exits the pelvis via the greater sciatic foramen.
Additionally, this helps free the lateral aspect of the
sacrum by releasing the coccygeus muscle with the
sacrospinous ligament. This is an important step
and aids with the sacrectomy. Furthermore, the sac-
rotuberous ligament is exposed, allowing it to be
transected if required. The Gigli saw is a useful tool
to transect the spine.
Tumour-encased external iliac vessels can be
resected as part of the en-bloc specimen, with the
assistance of a vascular surgeon. The vascular re-
construction results are most favourable with vein
grafts using the contralateral femoral vein and are
generally preferred over synthetic grafts. Where
possible, arterial reconstruction is best performed
immediately, rather than at completion of the ex-
enteration, to avoid compartment syndrome. The
encased external iliac vein may commonly be
thrombosed and laden with clot. This should be
identified during preoperative imaging and con-
sideration given to an inferior vena caval filter
08/02/13 5:34 PM

insertion before surgery to prevent propagation of
the thrombus and pulmonary emboli. In chronic
venous obstruction, reconstruction with an inter-
position venous graft is usually not necessary as
collaterals are already established.
Reconstruction
Urostomy: ileal and colonic urinary conduits
The ileum and colon have been used to create the
urostomy.16,58 In one study, there was no difference
in glomerular filtration rates or complications re-
lated to stenosis between the two types.58 Previ-
ously, ‘wet’ colostomies were performed to avoid
double stomas (colostomy and urostomy). There
are various methods for ureteric implantation. The
most common techniques used include bilateral
(Wallace) and single (Bricker) anastomoses. Uret-
eric stents are useful aids to promote healing and
protect the anastomosis.
Ureteric anastomotic leakage is a significant
complication and may require temporary bilateral
nephrostomies. The irradiated distal ileum and pel-
vic ureters increases the risk of anastomotic leaks.
To minimize this risk, the abdominal rather than
the pelvic ureter is used for the anastomosis. The
blood supply of the ureters is protected by not ‘skel-
etalizing’ the ureters during ureterolysis and pre-
serving the abdominal part of the gonadal vessels.
The use of a colonic urostomy may be worth con-
sidering as this avoids the use of radiation-damaged
distal ileum.
Perineal flap reconstruction
The perineal defect may be closed primarily or
with a pedicle flap. The most common types in-
clude the VRAM flap, gracilis myocutaneous flap
and gluteal myocutaneous rotational flap.25 Clos-
ing the defect with flaps has decreased the rate of
perineal wound complications, notably dehiscence.
Shibata and colleagues showed a significant reduc-
tion in major complications of the perineal wound
by closing the defect with a gracilis flap in patients
undergoing proctectomy following preoperative
radiation.59 Chessin and colleagues60 and Butler
and colleagues61 reported that perineal closure with
a rectus abdominis muscle flap post-irradiation
significantly reduced major perineal complications,
including dehiscence, compared with primary
HEBK001-C13_p203-221.indd 215
Surgical technique  215
closure. Similarly, the Mayo Clinic recommended
flap reconstruction over both primary closure and
primary closure with pedicled omentoplasty.62 Peri-
neal repair with a flap repair reduced wound-relat-
ed complications and length of hospital stay.
The pedicle flaps may also be used to reconstruct
the vagina after posterior vaginectomy. Bell and
colleagues reported a 20 per cent complication rate
with vaginal flap reconstruction.63 A small propor-
tion of patients will continue to have sexual inter-
course after vaginal reconstruction.63
Unresectable Local Pelvic
Recurrences
Up to 50 per cent of local recurrences present with-
out distant metastases and therefore are potentially
amenable to resection.21–45 Patients eligible, and se-
lected for pelvic exenteration may not proceed be-
yond a laparotomy due to the discovery of multifo-
cal disease or peritoneal dissemination.
Advancements in imaging modalities, especially
PET/CT and MRI, have decreased the rate of unnec-
essary laparotomies where extensive disease is discov-
ered and curative resection is not possible. Up to 5 per
cent of patients do not proceed to pelvic exenteration
due to previously undetected peritoneal disease or dis-
tant metastases detected intraoperatively.10
Factors Influencing Curative
Resection
Previously, LRRC has been deemed irresectable
when there is extension into the sciatic notch, en-
casement of the external iliac vessels, extension to
the sacral promontory, and the presence of lower
limb oedema from lymphatic or venous obstruc-
tion.16 When iliac vessel involvement was deter-
mined intraoperatively, R0 resection was signifi-
cantly less likely than when the vessels were not
involved.53 Curative pelvic exenterations with
transection of the involved sciatic nerve and resec-
tion of the external iliac vessels with reconstruction
have been performed successfully, however.
Radiological evidence of pelvic side-wall recur-
rence and hydroureter/hydronephrosis are signifi-
cant factors that limit an R0 resection but are not
contraindications for surgery. Involvement of the
08/02/13 5:34 PM
 216  Assessment and management of recurrence
genitourinary organs, piriformis muscle, iliac ves-
sels and sacrum do not influence margin status.53 If
the recurrence is proximal to S1, however, most in-
stitutions would not aim for a curative resection.16,57
Sacrectomy above S2 has a high morbidity, includ-
ing neuropathies and pelvic instability.
Post-operation
The patient should be transferred to the intensive
care unit from the operating theatre for initial post-
operative care. In general, patients who have had
exenterations completed within 10 h can be extu-
bated and transferred to the high dependency unit;
patients whose surgery is prolonged over 10 h re-
quire continued intubation and ventilation.
Early commencement of parenteral nutrition is
essential. Prolonged ileus is a common complica-
tion following exenteration surgery, and there-
fore enteral nutrition is not recommended. Total
parenteral nutrition is commenced on the first
postoperative day.
It is important to note that patients who un-
dergo sacrectomy or VRAM flap reconstruction
of the perineal or sacral defect should be nursed
in a 308 lateral tilt position to prevent pressure on
the surgical site. Upon stabilization, the patient
can then be transferred to a ward with special-
ized nursing and allied health staff experienced
in caring for patients with complex postoperative
needs.
Hospital stay can be prolonged and is usually de-
pendent on postoperative complications. The me-
dian hospital stay for pelvic exenteration involving
sacrectomy is 15 days (Table 13.3).64
Complications
The reported mortality rate has been low, rang-
ing from 0.3 per cent to 5.4 per cent.4,9,10,15–17,25 In
larger, more recent series, the mortality rate has
been reported at less than 1 per cent.9,10,17 Occa-
sional perioperative death may result from uncon-
trollable pelvic haemorrhage and cardiorespira-
tory events. The modern results are a significant
improvement from the historically high mortality
rates (10 per cent or more) of the pioneering era of
pelvic exenteration.
HEBK001-C13_p203-221.indd 216
Table 13.3. Pelvic exenteration operative and admission
detailsa.
Median operating time 9 h (range 3–16 h)
Median blood transfusion rate 6.6 units (range 0–17 units)
Mean number of specialties 3 (range 1–5)
  involved
Median number of days in ICU 3 days (range 0–11 days)
Mean number of days in hospital 25 days (range 5–126 days)
Median number of days in 15 days
  hospital
a
Unpublished data from Royal Prince Alfred Hospital
Pelvic Exenteration database, Sydney, Australia (n 5 240
cases).
ICU, intensive care unit.
The published morbidity rates range from 21
per cent to 72 per cent.1,49,51 Larger, more recent
series from major institutions report morbidity
rates of 23–27 per cent.9,10,17 The most common
complications include perineal wound dehis-
cence, pelvic collections and cardiorespiratory
problems. A more comprehensive list is shown in
Table 13.4.
Prognosis
Factors that affect survival have been extensively
analysed and reported. Reported factors include
margin status, site of pelvic recurrence, number
of points of fixity, lymph node status at primary
surgery, intraoperative radiotherapy, preopera-
tive and postoperative adjuvant therapy, CEA
levels, symptoms related to recurrence (especially
pain), extent of resection, and operation type at
primary resection.9,10,15–17,28,51,53,57 Statistically sig-
nificant negative prognostic indicators are listed
in Table 13.5.
Resection margins have consistently been
shown to be the most significant factor on sur-
vival.4,9,10,15–18 If microscopic clear margins are
achieved, then survival is significantly improved
compared with positive margins. R0 resection
margins have been achieved in 38–84 per cent of
patients.4,10,15–17 The 5-year overall survival rates
for R0 resection range from 23 per cent to 49 per
cent.9,10,16,17,57 If the margins are positive, however,
then the 5-year survival decreases significantly to
0–23 per cent.9,10,15–17
08/02/13 5:34 PM
 Prognosis  217

Table 13.4. Complications. Table 13.5. Negative prognostic indicators for survival.
Perineal Positive margin
  Wound dehiscence Lateral pelvic side-wall recurrence
  Persistent perineal sinus Number of fixed points in the pelvis
  Perineal flap necrosis Positive lymph node at primary surgery
Pelvic collection Elevated carcinoembryonic antigen level
  Wound infection Presentation with pain
  Pelvic abscess/haematoma Sciatic nerve involvement
Gastrointestinal
  Prolonged ileus (R1 or R2) had a lower 5-year survival rate at 16 per
 Enterocutaneous fistula cent (R1, 22 per cent; R2, 15 per cent) when com-
  Anastomotic leak
pared with a curative resection (R0, 37 per cent).9
These finding are consistent with the data from
  Bowel obstruction
other exenteration units, including Leeds General
Cardiorespiratory/vascular
Infirmary, the Memorial Sloan Kettering group and
  Atrial fibrillation
the Japanese reports (Table 13.6).
  Myocardial infarction The extent of resection did not significantly in-
  Pneumonia fluence survival if R0 resection was achieved.9,10,16,18
 Deep venous thrombosis This is consistent with the principles of surgical
 Chronic lower limb oedema oncology. The ‘holy grail’ of exenteration surgery is
Urological
thus an R0 resection.
Patterns of pelvic recurrence have been studied
 Urinary retention
by Yamada and colleagues.28 Five-year survival
 Ileal conduit leak
rates varied, depending on the original site of
 Colovesical fistula recurrence. Localized recurrence (i.e. recurrence
Neurological involving adjacent organs) had a 5-year survival
  Sciatic nerve palsy of 38 per cent, compared with 10 per cent in pa-
 Obturator nerve palsy tients with sacral invasion and 0 per cent in pa-
tients with lateral recurrence. Lateral recurrence
has been observed as a negative prognostic in-
An extensive pooled analysis of 1569 patients dicator by other authors.10,53 Lateral recurrences
who underwent pelvic exenteration surgery was have inferior results because of the anatomical
published in 2006.5 The overall 5-year survival rate limitations determining resectability. Bone and
was 30.7 per cent. Analysis of the specimens with major pelvic side-wall vessels limit the lateral
clear margins (R0) showed an improvement in the extent of resection. In recent years, extended
5-year survival rate up to 38.2 per cent. Heriot and radical resections including the iliac vessels have
colleagues reported similar survival rates from 160 been performed with encouraging results. Over
patients across three different institutions.10 The the past decade, the Royal Prince Alfred Group
overall 5-year survival was 36.6 per cent. The 5-year in Sydney has implemented a surgical approach
survival rate for negative resection margins (R0) for lateral pelvic wall recurrences.42 The R0 resec-
was significantly higher when compared with those tion rate for lateral pelvic recurrences was as high
with involved margins. Overall, 61 per cent were R0 as 53 per cent, and the overall survival rate was
resections with a 5-year survival rate of 49 per cent, 69 per cent at 19 months’ follow-up. R0 resection
and 25 per cent were positive microscopically (R1) was associated with 46 per cent of patients re-
with a 5-year survival rate of 21 per cent. Macro- maining disease free, with an average disease-free
scopic involvement in 9 per cent of patients resulted interval of 30 months.3
in a 5-year survival rate of 17 per cent. Similarly, An increasing number of fixed points of the re-
the Mayo Clinic reported its series of 304 patients current cancer has been shown to have a poorer
and demonstrated that positive resection margins outcome.9,53

HEBK001-C13_p203-221.indd 217 08/02/13 5:34 PM

 218  Assessment and management of recurrence

Table 13.6. Resection margins (R0–2) and 5-year survival rates.

5-year 5-year 5-year
Study n R0 (n [%]) survival (%) R1 (n [%]) survival (%) R2 (n [%]) survival (%)
Kusters et al.65 170 92 (54) 40
Heriot et al.10 160 98 (61) 49 40 (25) 21 14 (9) 17
Bell et al.
63
51 41 (80) a
10 (20) a

Bedrosian et al.15 134 65 (49) 30 20 (15) 15 13 (10)

Wiig et al. 66
150 66 (44) 27
Boyle et al.4 64 24 (38)b 24 (38)b 9 (14)b
Moore et al.53 119c 61 (51) 38 (31) 7 (7)
Moriya et al. 16
57 48 (84) 42 9 (16)d 0
Hahnloser et al.9 304 138 (48) 37 27 (6) 22 139 (46) 14
Yamada et al. 57
42 30 (71) 23 12 (29) e
0
Salo et al.17 131 71 (54) 35 13 (10) 23 19 (15) 9

The difference after the sum of all the resections in those patients who had a laparotomy with curative intent but did
not have a resection.
a
4-year survival: R0 41%, R1 10%.
b
3-year survival: R0 68%, R1 34%.
c
18 recurrences from colonic cancers.
d
9 positive margins. 3 had palliative intraoperative radiotherapy. 5-year survival was 0 for positive margins. All
resections includes sacrectomies.
e
12 palliative resections. All 42 patients had sacrectomies.

Some authors have concluded that an elevated
CEA has a worse prognosis,15–17 but other reports
are inconclusive.10,25
Survival
Wanebo and colleagues reported their series in
1999.25 The overall 5-year survival rate was 31 per
cent, with a 5-year disease-free survival rate of 23
per cent. More recent series report overall 5-year
survival rates in the range 25–37 per cent, with a
median overall survival of 31–43 months.9,10,15,16
The median cancer-specific survival has been re-
ported at 48 months,10 with a cancer-specific 5-year
survival rate in the range 36–41.5 per cent.10,15,16 The
overall survival rate after a curative histological re-
section is in the range 23–49 per cent.2,4,9,10,15,17,18,53,57
Quality of Life
The long-term quality of life in survivors of pelvic ex-
enteration for recurrent and locally advanced primary
rectal cancer is comparable to that in patients who
have undergone primary rectal cancer resections. The
quality of life survey performed by Austin and col-
leagues showed that patients suffered more in physi-
cal than mental terms following pelvic exenteration,
but their overall quality of life was comparable to that
in the general population.67 Miller and colleagues as-
sessed quality of life and cost-effectiveness of therapy
for LRRC; they concluded:
… surgical resection was a cost-effective treat-
ment for recurrent rectal cancer compared with
non-operative and palliative strategies. Moreover,
the procedure to elicit utility values showed that
patients were more willing to gamble the risks of
surgery and the possibility of developing pain or
complications to have an opportunity to extend life
than were health care providers. An incremental
analysis was performed to combine the costs and
benefits of each strategy. The incremental cost–
utility ratio was $109 777 per QALY [quality-
adjusted life-year] for the surgical resection
compared with the non-operative therapy from the
health care provider point of view, and $56  698
from the patient view. The diagnostic or palliative
surgery strategy was always dominated by the
non-operative option (less costly and more effec-
tive in terms of survival rate).13

HEBK001-C13_p203-221.indd 218 08/02/13 5:34 PM


Following pelvic exenteration, patients report an
improvement in their quality of life and a reduc-
tion in pain. In addition, their quality of life is bet-
ter than in patients who receive medical palliative
treatment.11–13
Re-recurrence
A second local recurrence occurs in approximately
a third of patients after initial surgery for local re-
currence.68 Bedrosian and colleagues15 and Garcia-
Aguilar and colleagues19 believe that LRRCs are
biological variants with fewer tendencies to metas-
tasize. Garcia-Aguilar and colleagues reported that
9 of 14 local recurrences did not metastasize.19
Bedrosian and colleagues showed that metastatic
disease occurred earlier than the development of a
second recurrence (9 months v. 16.5 months). Pa-
tients lived longer after the second local recurrence
(41.5 months) compared with patients who devel-
oped metastatic disease (26.1 months).15 There was
no significant difference in the rate of a second re-
currence between an R0 or R1 resection from the
initial local recurrence surgery.4 The authors stated
that they were uncertain of the microscopic margin
status of a second recurrence. Additionally, histolog-
ical orientation and evaluation of the ‘true’ margins
may be inaccurate, especially when the specimen
becomes fragmented.4 Median survival is improved
with R0 resection,54 but other series report no dif-
ference between R0 and R1 resections.17,66
Palliative surgery
Consistent results have shown that a negative margin
for malignancy is the key factor in survival – hence, the
ethical debate about palliative surgery arises. Involved
surgical margins after pelvic exenteration generally re-
sults in poor survival rates and poor quality of life,9,67
and therefore it is debatable as to whether it is justifi-
able to perform extensive surgery with considerable
morbidity to prolong life for a short period.
Patients with advanced recurrent pelvic disease
commonly have intractable pelvic pain and malo-
dorous perineal discharge associated with a signifi-
cant decline in their quality of life. In this scenario,
pelvic exenteration can be recommended only if
surgery is for cure. Similarly, we recommend that
HEBK001-C13_p203-221.indd 219
References  219
patients with fistulating disease and small bowel
obstruction have pelvic exenteration surgery only
if cure is possible, otherwise a bowel bypass with
anastomosis or a stoma should be considered in the
palliative scenario.
Patients with limited and resectable metastatic
disease of the liver or lung may be considered for
pelvic exenteration if there is potential for cure or
at least disease control.
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08/02/13 5:34 PM

Lateral pelvic side-wall nodal
involvement in rectal cancer
Hideaki Yano and Brendan Moran
Introduction
The risk of metastasis to, and clinical significance
of, lateral pelvic side-wall nodes in rectal cancer re-
mains controversial, although there is now general
agreement that involved pelvic side-wall nodes are
more common with low rectal cancer.1 Removal of
these nodes, i.e. lateral pelvic lymph node dissec-
tion (LPLD), in addition to total mesorectal exci-
sion (TME) is considered a major mechanism in re-
ducing local recurrence and improving survival in
Japan (Figure 14.1).2,3 The rationale behind this ap-
proach is that lateral pelvic side-wall nodal involve-
ment is pathologically confirmed in 10–20 per cent
of patients with low rectal cancer, and a consider-
able number of patients with lateral pelvic side-wall
nodal involvement survived free of disease after
LPLD even before the modern chemotherapy era.
Over the past two decades, LPLD has been con-
tinuously developed and refined in Japan, with a
more selective approach in high-risk patients and
widespread use of autonomic nerve-preserving
techniques.1
In Europe and North America, however, the ap-
proach has been either to ignore lateral pelvic side-
wall nodes or to treat obviously involved nodes
with radiotherapy or, more commonly, chemora-
diotherapy. Lateral pelvic lymph node dissection
HEBK001-C14_p222-227.indd 222
14
has been practically abandoned and has not been
performed due to the following issues:
l LPLD is associated with high morbidity;
l lateral pelvic side-wall nodal involvement was
considered rare in the West compared with
Japan and the East;
l involved lateral pelvic side-wall nodes have
generally been considered to indicate systemic
disease not amenable to surgery.
Advances in pelvic imaging, however, particular-
ly computed tomography (CT) and magnetic reso-
nance imaging (MRI), with the ability to visualize
and categorize lymph nodes, together with reviews
of the published literature, suggest that lateral nod-
al involvement rates may be similar in the West and
the East and are a particular problem in low rectal
cancer.1
INCIDENCE OF LATERAL PELVIC
SIDE-WALL NODE INVOLVEMENT
In addition to the predominant lymphatic rectal
drainage that runs upwards or proximally within the
mesorectum, the lower rectum has lateral lymphatic
drainage, which may result in involvement of lateral
pelvic side-wall nodes (Figure 14.2). This anatomical
11/02/13 3:59 PM
 INCIDENCE OF LATERAL PELVIC SIDE-WALL NODE INVOLVEMENT  223

Figure 14.1. Lateral pelvic lymph node dissection on the left pelvic side-wall.

feature pertaining to the low rectum has been sup-
ported not only by numerous experimental studies
using dye injection and lymphoscintigraphy but also
by clinical observations.1,4 A multicentre study in Ja-
pan that recruited 2916 patients with rectal cancer
reported lateral pelvic side-wall node involvement in
20.1 per cent of patients with T3/4 low rectal cancer
lying at or below the peritoneal reflection.2 It is note-
worthy that the lower the tumour is, the higher the
risk of lateral pelvic side-wall node involvement.5
A number of risk factors have been reported to
predict lateral pelvic side-wall nodal metastasis.
Modern pelvic imaging by CT or MRI allows visu-
alization of suspicious pelvic side-wall nodes, and
studies are ongoing to define the sensitivity and
specificity of imaging in determining the status of
pelvic side-wall nodes. This correlation can only
be truly documented in patients who have imaging
followed by LPLD without neoadjuvant therapy.
In addition to modern imaging of the nodes, re-
ported predictive factors for lateral nodal involvement
include positive mesorectal nodal status, height of the
tumour, depth of tumour invasion, histological grade,
lymphovascular invasion, size of the tumour and fe-
male sex.1,2,6 Some factors can be determined or reliably
predicted before surgery, but others can be determined
only after surgery. A prospective study reported a high
diagnostic accuracy of CT scanning in predicting

Upward
spread

Lateral
spread
Pelvic
plexus

Figure 14.2. Lymphatic drainage from the low rectum exists in the space between the pelvic plexus and the lateral pelvic
side-wall.

HEBK001-C14_p222-227.indd 223 11/02/13 3:59 PM

 224  Lateral pelvic side-wall nodal involvement in rectal cancer
Figure 14.3. Imaging suggestive of right lateral pelvic side-wall node involvement.
lateral pelvic side-wall node involvement, allowing pr-
eoperative identification of patients most likely to ben-
efit from extended dissection (LPLD) (Figure 14.3).7
In future, MRI or positron-emission tomography
(PET) techniques may further enhance the selection
of patients for appropriate treatment.
Lateral pelvic side-wall
node involvement: local
or systemic disease?
Controversy exists as to whether involved pelvic
side-wall nodes represent systemic disease or local-
ized disease that is amenable to surgery. The previ-
ously mentioned large multicentre study reported
that the 5-year survival rate of patients with lateral
pelvic side-wall node involvement was 45.8 per
cent, which surpasses the outcomes following liver
resection for hepatic metastasis.2
Patients with lateral pelvic side-wall node in-
volvement constitute a heterogeneous group. In
some patients the disease is undoubtedly systemic
and carries a poor prognosis, indicating a need for
neoadjuvant and adjuvant treatment or even pal-
liative care. Other patients have localized disease as
demonstrated by favourable 5-year survival rates
achieved with LPLD.
OPERATION
In contrast to Western countries, LPLD has been
continuously promoted, performed and refined
HEBK001-C14_p222-227.indd 224
in Japan. Key refinements have been a more
patient-selective approach and nerve-preserving
surgery.1
Lateral pelvic lymph node dissection for upper
rectal cancer has been almost abandoned in Japan
with a highly selective approach to LPLD. Based on
the large multicentre study, the Japanese guidelines
now suggest LPLD for T3/4 rectal cancer with its
lower edge lying at or below the peritoneal reflec-
tion.8 There is a problem with these criteria be-
cause the precise depth of the tumour cannot be
determined accurately preoperatively; lateral pelvic
side-wall nodal involvement was confirmed in only
20 per cent of the patients who had LPLD; and lat-
eral pelvic side-wall node involvement was found
in 9.2 per cent of T2 low rectal cancers and would
not have been removed based on these criteria. A
further controversial issue is whether ‘prophylac-
tic’ LPLD for advanced low rectal cancer offers any
survival benefit. This depends on the accuracy of
preoperative assessment of tumour depth, nodal in-
volvement and other preoperative factors.
Lateral pelvic lymph node dissection is known
to be associated with significant morbidity, longer
operating time, greater blood loss and genitouri-
nary dysfunction. Nerve-sparing techniques have
been developed and refined, with marked improve-
ments in urinary and sexual function in recent
years.9,10 There are concerns, however, as to whether
preservation of autonomic nerves, particularly the
inferior hypogastric plexus, may compromise the
oncological outcomes when cancer cells are likely
to have metastasized through the lateral lymphatic
channels to the lateral pelvic side-wall nodes.
11/02/13 3:59 PM

Figure 14.4. Dissection between the external iliac artery
and the psoas major muscle.
Operative Techniques
Lateral pelvic lymph node dissection is usually per-
formed following completion of rectal resection
using the principles of TME or sphincter resection
in patients who require abdominoperineal excision.
In restorative procedures, LPLD is performed be-
fore the anastomosis.
If there are concerns about the margins of the
suspicious nodes, the internal iliac artery or vein
and the autonomic nerves, i.e. inferior hypogastric
plexus (pelvic plexus), should be excised en bloc.
The main aspects of LPLD on the right pelvic
side-wall are as follows:
The hypogastric nerve is secured using a vessel
loop or tape. Caudally, the inferior hypogastric plexus
and the pelvic splanchnic nerves (nervi erigentes) are
dissected off the parietal endopelvic fascia and pre-
Figure 14.6. Dissection of the obturator region.
HEBK001-C14_p222-227.indd 225
OPERATION  225
Figure 14.5. Dissection of the medial aspect of the
external iliac vessels.
served. The ureter is then secured using a vessel loop
or tape to reduce the risk of inadvertent damage.
The external iliac artery is exposed and secured
using a vessel loop or tape. By exposing the medial
aspect of the psoas major muscle, the fat tissue
between the external iliac artery and the psoas
major is dissected and the obturator nerve is
identified (Figure 14.4). Care should be taken not to
damage the fifth lumbar vein that drains into either
the inferior vena cava or the external iliac vein.
Before dissection of the obturator region, the an-
terior aspect of the internal iliac artery is exposed
and the fat tissue surrounding the external iliac vein
is dissected from the cranial to the caudal direction.
There is generally no need to follow the external
iliac vessels to their distal ends, unless there is sus-
picious tissue there, as this may increase the risk of
lymphoedema of the leg (Figure 14.5).
11/02/13 3:59 PM
 226  Lateral pelvic side-wall nodal involvement in rectal cancer
Figure 14.7. Dissection of the dorsal aspect of the
obturator region.
By retracting the ureter and the external iliac
vessels laterally, the optimal surgical field will be
obtained. The dissection of the obturator region is
commenced from where the internal and external
iliac arteries branch off the common iliac artery. The
superior vesical artery and the obturator vessels are
then identified, both of which can be excised if nec-
essary. Retracting the superior vesical artery medi-
ally, dissection is continued by exposing the obtura-
tor nerve and the internal obturator muscle as far as
the point where the nerve enters the obturator canal
(Figure 14.6). When using diathermy dissection, lo-
cal injection of lidocaine is very helpful to prevent
stimulation of the adductor muscles. Alternatively,
ultrasonic coagulating shears may prove useful.
On the craniomedial aspect, the lymphatic tis-
sue is dissected off the internal iliac vessels that are
Figure 14.8. Dissection of the caudal aspect of the
obturator region.
HEBK001-C14_p222-227.indd 226
Figure 14.9. Identification of the inferior vesical vessels.
situated on the lumbosacral trunk and the sacral
nerve plexus (Figure 14.7). Care should be taken,
particularly if excising the internal iliac vessels, not
to damage the small branches of the vein, which can
result in considerable bleeding.
The caudal part of the obturator area is dissected
by pulling medially the superior vesical artery and the
ureter. The levator ani muscle is exposed just caudal
to the internal obturator muscle (Figure 14.8).
More medially, identification of the inferior
vesical vessels that are situated just lateral to the
inferior hypogastric plexus is important. This is
followed by division of the distal branches of the
inferior vesical artery and vein at the point just
proximal to the bladder (Figure 14.9). Lateral pel-
vic lymph node dissection is completed by divid-
ing the inferior vesical vessels from the internal
iliac vessels (Figures 14.10 and 14.11).
Figure 14.10. Division of the inferior vesical vessels.
11/02/13 3:59 PM

Figure 14.11. View after completion of lateral pelvic lymph
node dissection on right pelvic side-wall.
References
  1. Yano H, Moran BJ. The incidence of lateral pelvic side-
wall nodal involvement in low rectal cancer may be
similar in Japan and the West. Br J Surg 2008;
95: 33–49.
  2. Sugihara K, Kobayashi H, Kato T, et al. Indication and
benefit of pelvic sidewall dissection for rectal cancer.
Dis Colon Rectum 2006; 49: 1663–72.
  3. Kusters M, Beets GL, van de Velde CJH, et al. A com-
parison between the treatment of low rectal cancer in
HEBK001-C14_p222-227.indd 227
References  227
Japan and Netherlands, focusing on the patterns of
local recurrence. Ann Surg 2009; 249: 229–35.
  4. Bell S, Sasaki J, Sinclair G, et al. Understanding the
anatomy of lymphatic drainage and the use of blue-
dye mapping to determine the extent of lymphadenec-
tomy in rectal cancer surgery: unresolved issues.
Colorectal Dis 2009; 11: 443–9.
  5. Ueno M, Oya M, Azekura K, et al. Incidence and prog-
nostic significance of lateral lymph node metastasis in
patients with advanced low rectal cancer. Br J Surg
2005; 92: 756–63.
  6. Ueno H, Yamauchi C, Hase K, et al. Clinicopathologi-
cal study of intrapelvic cancer spread to the iliac area
in lower rectal adenocarcinoma by serial sectioning.
Br J Surg 1999; 86: 1532–7.
  7. Yano H, Saito Y, Takeshita E, et al. Prediction of lateral
pelvic node involvement in low rectal cancer by con-
ventional computed tomography. Br J Surg 2007;
94: 1014–9.
  8. Japanese Society for Cancer of the Colon and Rectum
(ed.). JSCCR Guidelines 2010 for the Treatment of
Colorectal Cancer, 2nd edn. Tokyo, Kanehara & Co.,
2010: 13–5.
  9. Moriya Y, Sugihara K, Akasu T, Fujita S. Nerve-sparing
surgery with lateral node dissection for advanced lower
rectal cancer. Eur J Cancer 1995; 31A: 1229–32.
10. Matsuoka H, Masaki T, Sugiyama M, Atomi Y. Impact
of lateral pelvic lymph node dissection on evacuatory
and urinary functions following low anterior resection
for advanced rectal carcinoma. Langenbecks Arch
Surg 2005; 390: 517–22.
11/02/13 3:59 PM

Intestinal stoma and the role
of defunctioning a low anastomosis
after anterior resection
David Mitchell, Kandiah Chandrakumaran and Steven Arnold
Introduction
Surgeons have been constructing intestinal stomas
for over 200 years, but the modern ileostomy and
colostomy have been developed from our predeces-
sors’ trial and error.
Littre proposed the ‘inguinal colostomy’ in 1710
for infantile imperforate anus but never actually
performed the operation. It took more than 65 years
before the first stoma was performed in 1776, when
French surgeon Pillore created a defunctioning
stoma for obstructing rectal cancer on Monsieur
Morel. This was a caecostomy and the patient died
after 28 days from complications not directly relat-
ed to the stoma; this was not reported in the medi-
cal press until 1840. In 1783, Dubois performed the
first ‘Littre’s operation’ on a 3-day-old infant for
imperforate anus, but the baby died on the tenth
day. The first successful colostomy was performed
in 1793 by Duret, on an infant with a maldeveloped
perineum and absence of the rectum.
With the advent of anaesthesia, diversion colos-
tomy became popular for the management of large
bowel obstruction. In the early days there was a
high mortality rate. Amussant, a Parisian surgeon,
attributed this high mortality rate to peritonitis as
a result of opening the peritoneum. He suggested
HEBK001-C15_p228-238.indd 228
15
accessing the colon in the lumbar region without
opening the peritoneum. A few surgeons attempted
this procedure but failed, and the approach was
rapidly abandoned. The first panproctocolectomy
and ileostomy was performed by Miller in 1949.
When total mesorectal excision (TME) is per-
formed, with a very low division of the muscle tube
to enable re-anastomosis, most surgeons would
elect to use a proximal defunctioning stoma to re-
duce the consequences and possibly the incidence
of anastomotic leakage. It has been well reported
that when a low rectal anastomosis is performed
(by definition, less than 7 cm from the anal verge
on rigid sigmoidoscopy), then the risk of an anas-
tomotic leak rises significantly; the lower the anas-
tomosis, the higher the risk.1
The term ‘anterior resection’ by definition involves
an operation whereby the superior rectal artery has
been ligated and the anastomosis has been performed
to the top of the rectum. The term is increasingly used
for surgical management of pathology of the sigmoid
colon, especially in the laparoscopic era, where the
technique enables modern stapling guns to construct
the anastomosis without the need for intracorporeal
suturing. Even when resection of the upper rectum is
added, the resulting anastomosis is relatively high, the
risks of anastomotic leakage are much reduced, and a
08/02/13 5:29 PM

stoma is frequently unnecessary and can be avoided.
An ‘anterior resection’ involving TME down to the
pelvic floor, however, is a different matter, with much
higher risks of leakage.
PREOPERATIVE PLANNING
Almost all TME operations will be scheduled elec-
tively. This gives the patient and team the chance to
prepare for the high likelihood of needing a stoma.
Preoperatively, there may be the opportunity to
meet another patient with a stoma, thereby allow-
ing personal questions and expectations to be ad-
dressed. The patient should meet a specialist stoma
nurse (stomatherapist), who has a key role to play
in the preoperative preparation and peri- and post-
operative management.
Optimal abdominal wall stoma siting is a crucial
step in successful outcome. The aim is to locate a
flat smooth skin surface so that stoma appliances
can be fitted with as near perfect seal as possible.
This reduces the likelihood of leaking and skin ex-
coriation caused by irritant gastrointestinal con-
tents. The patient and stoma nurse carefully consid-
er factors such as abdominal shape, previous scars,
and where the patient can physically see when se-
lecting and marking a suitable stoma site. Personal
factors such as clothing styles and where belts are
worn are also considered. Siting is carried out away
from bony landmarks, and skinfolds are avoided to
prevent the stoma from lying in a crease when the
patient is sitting upright. Note that skinfolds may
not be apparent when the patient is supine dur-
ing the operation. Some surgeons have suggested
that the risk of developing a parastomal hernia is
reduced when the bowel is brought through the
rectus abdominis muscle, and hence the stoma site
is marked medial to the lateral edge of the rectus
abdominis muscle. Once a suitable site is identified,
the site is marked with an indelible marker pen.
The site can then be covered with a clear adhesive
plastic dressing, thereby preventing the mark from
becoming faint or rubbing off. It is good practice to
have both left- and right-sided stoma sites marked
as surgery may not progress according to plan,
thereby allowing both a defunctioning ileostomy or
an end colostomy formation. Pre-existing marks al-
low whichever stoma is necessary to be formed in a
good position. The authors favour the practice of
HEBK001-C15_p228-238.indd 229
LOOP ILEOSTOMY  229
marking stoma sites with either surgical skin clips
or a silk stitch as soon as the patient is prepared
and draped, as the ink marks may completely rub
off during the operation, especially if the adhesive
dressing is removed for skin preparation.
In the emergency situation, it may not be pos-
sible to have optimal planning for siting a stoma,
such as surgery for obstruction, bleeding, ischaemia
or abdominal trauma. Nevertheless, the surgeon
should take account of all of the above factors when
choosing where to site a necessary stoma, as the
­patient may have the stoma long term and often
indefinitely.
A major role of the stomatherapist is to provide
the patient with preoperative counselling. It has
been reported that the presence of a stoma may de-
lay the discharge of an otherwise well patient by as
much as 4 days.2 With the drive towards enhanced
recovery and early discharge, preoperative training
in the care, emptying and changing of a stoma bag
may hasten the patient’s discharge. It is essential to
provide contact numbers of the stoma care team to
the patient on discharge so that they can access spe-
cialist help quickly in the event of problems.
It is important to note that a stoma may have
profound impact on a patient’s life. Body dysmor-
phia is common and the impact is dramatically in-
creased by leaking and poorly functioning stomas.
Therefore, the surgeon should take the utmost care
and exemplary surgical techniques to avoid any
complications. This may be especially important to
remember at the end of a long operation such as
TME for rectal cancer or total colectomy.
LOOP ILEOSTOMY
A loop ileostomy is most commonly used to de-
function a low rectal anastomosis (Figure 15.1). A
loop ileostomy appears to have become the pro-
cedure of choice in most units for defunctioning
a low rectal anastomosis and has superseded the
equally effective loop colostomy for defunctioning.
A suitable point on the terminal ileum is selected.
This is usually about 25–30 cm proximal to the ile-
ocaecal valve. If it is nearer to the ileocaecal valve,
then in theory back pressure on the segment at
the time of stoma reversal may increase the likeli-
hood of a leak from the ileostomy closure site. A
disc of skin and underlying fat is then excised at
08/02/13 5:29 PM
 230  Intestinal stoma and the role of defunctioning a low anastomosis after anterior resection
the marked site and the underlying sheath exposed.
The assistant can attach a Littlewoods or similar in-
strument to the edge of the midline sheath, allow-
ing gentle traction to straighten the abdominal wall
so the stoma can be brought out straight. Tradition-
ally a cruciate incision was made in the sheath, but
a longitudinal incision is now recommended; the
underlying rectus muscle fibres are gently separated
with Langenbeck’s retractors to expose the poste-
rior rectus sheath. This is then incised and then
gently stretched to permit the formation of the
stoma. Inserting two fingers through the site usu-
ally allows enough stretching for easy passage of the
bowel, without leading to too big a defect with an
increased risk of subsequent herniation. Babcock’s
forceps are ideal for passing through the site, grasp-
ing the small bowel, and gently guiding the bowel
through the abdominal wall. Orientation of the
intra-abdominal small bowel is checked, preferably
with the efferent limb positioned superiorly. At least
6 cm of bowel, measured on the antimesenteric bor-
der, should be delivered, to allow sufficient length
for formation of a good spout. Before closing the
abdomen, two or three dissolvable sutures are in-
Proximal
spouted
end
Distal flush
end
Figure 15.1. Loop ileostomy.
HEBK001-C15_p228-238.indd 230
serted inferiorly, attaching the small bowel to the
skin. This holds the loop in place and marks where
the flush afferent limb will be attached to the skin.
Following closure and protection of the main
wound, the ileostomy can then be formed. The il-
eum is opened transversely by an incision a couple
of millimetres above the previously placed effer-
ent small bowel-to-skin sutures. This incision is
extended for about two-thirds of the circumfer-
ence of the bowel, but preserving the mesenteric
border, which is left in continuity. Three eversion
sutures are then placed at the 12, 3 and 9 o’clock
positions. Dissolvable sutures are preferred, such as
3.0 monocryl or vicryl rapide. The superior-most
stitch is then used to take a seromuscular bite ap-
proximately 6 cm proximal to the cut end of the
bowel, with the two side sutures taking a similar
bite at approximately 5 cm from the cut end of the
small bowel. Once all three are in situ, gentle trac-
tion on all three usually results in eversion of the
bowel to form a spout approximately 2.5 cm long,
facing slightly downwards. Sometimes gentle assist-
ance is required to evert the spout, and the blunt
end of Langenbeck’s retractors can be used to facili-
tate this. Once these stitches are secure, further su-
tures can be placed between them to secure the new
mucocutaneous junction around the circumference
of the stoma. Haemostasis is then checked, and a
stoma bag can be cut to shape and fitted.
End ileostomy
In the event of a panproctocolectomy (e.g. a patient
with rectal cancer on a background of ulcerative
colitis), an end ileostomy must be fashioned. After
removing the large bowel, a disc of skin is excised
from the abdominal wall at the marked site, along
with a disc of subcutaneous fat. The terminal ileum
will usually have been cross-stapled and divided
close to the caecum. After entering the abdominal
cavity as for a loop ileostomy, the end of the ileum
is grasped gently with Babcock’s forceps and with-
drawn through the opening. The mesentery supply-
ing the end of the bowel is also brought through;
care must be taken not to traumatize the mesentery
and risk a haematoma or disruption of the blood
supply. Small bowel orientation is checked to en-
sure no rotation of the mesentery, and the laparot-
omy wound is closed.
08/02/13 5:29 PM

The staple line is cut off and a spout is created
similar to the technique described above. The au-
thors use four sutures placed at 6, 9, 12 and 3 o’clock
on the circumference of the open small bowel, go-
ing from inside out and then through the serosa
and muscle of the proximal small bowel 6 cm from
the cut end for the uppermost two sutures and 5 cm
from the end for the lower two sutures. Traction on
all four sutures usually inverts the bowel to produce
a spout; the slightly longer uppermost length pro-
duces a downward tilt at rest to direct liquid con-
tents into a stoma bag. The sutures are tied and held
on forceps while intervening sutures are placed.
Loop colostomy
A transverse loop colostomy is a good alternative
defunctioning stoma, and a premarked site will
usually be in the right upper quadrant. Once the
rectal anastomosis is completed, the portion of the
transverse colon that can be exteriorized at the pr-
eoperatively marked site is selected. It is important
that there is no undue tension on the mesentery or
appearances of ischaemia; full mobilization of the
hepatic flexure may be required. An ellipse of skin
is removed and the subcutaneous fat is split and re-
tracted with Langenbach’s retractors. The anterior
rectus sheath is exposed and a cruciate or linear
fascial incision made. The rectus abdominis muscle
is split longitudinally. Great care must be taken to
avoid injury to the inferior epigastric vessels. The
peritoneum is opened and the selected portion of
the colon is exteriorized with Babcock’s forceps.
A useful technique is to pass a length of tubing
around the transverse colon, through an avascular
area in the mesentery, and use this to pull the colon
through the abdominal wall opening. It is impor-
tant at this stage to ensure that the orientation is
correct, there is no undue tension and the opening
is adequate. In patients who are obese, it may be nec-
essary to widen the opening to ensure this. A cou-
ple of ‘stay’ sutures are applied and the laparotomy
wound is closed in the usual manner. The wound
is dressed and protected. A transverse enterotomy
is made in the loop, to include approximately two-
thirds of the circumference, and the bowel ends
are cleaned with povidone–iodine. Haemostasis is
achieved, and interrupted absorbable stitches are
applied to approximate the open edge of the colon
HEBK001-C15_p228-238.indd 231
ALTERNATIVES  231
to skin. These should be placed in an extramucosal
fashion. It is common to use a ‘bridge’ under the co-
lonic loop, either purpose-designed or an adapted
piece of tubing (as described above to pull out the
loop), to help support the stoma. This is removed
at 5–7 days. The disadvantage of a bridge is that it
interferes with appliance application and changing.
A loop colostomy may also be required in some
very symptomatic patients with rectal cancer before
neoadjuvant chemoradiotherapy or occasionally
to relieve obstruction. The traditional trephine co-
lostomy method should now be almost exclusively
replaced by a laparoscopic technique to obviate
the reported risks of bringing the wrong end of a
stoma or a rotated loop via a trephine. Difficulty
often arose in correctly identifying the orientation,
especially with redundant sigmoid or transverse co-
lon. A laparoscopic technique is optimal to assess
the mesenteric length, allow mobilization and con-
firm orientation. If a trephine sigmoid colostomy is
being performed, a useful technique is to intubate
the colon peranally using a flexible sigmoidoscope.
If using a sigmoidoscope, it is important not to
inflate too much air and to limit insufflation to a
­minimum.
End colostomy
An end colostomy is performed after abdomi-
noperineal excision of the rectum and in some
emergencies in the form of a Hartmann’s proce-
dure. In both cases, the distal end of the proximal
colon is usually stapled closed during the laparot-
omy, until the specimen is dissected and removed.
The closed end is then exteriorized through the
­preoperatively marked site, without tension, similar
to a loop colostomy. Scissors can be used to excise
the staple line, and the edges of the colon and skin
are approximated with circumferential interrupted
absorbable sutures.
ALTERNATIVES
Although formal proximal defunctioning gives the
best protection to a distal anastomosis, alternative
measures have been described.
Caecostomy (intubation of the caecum, usually
with a urinary catheter) has been used, although
08/02/13 5:29 PM
 232  Intestinal stoma and the role of defunctioning a low anastomosis after anterior resection
the procedure is largely historic. The appendix was
amputated and the stump brought on to a small
opening on the abdominal wall, in the right iliac
fossa. The hypothesis was that a caecostomy al-
lowed some venting of the accumulated gas, there-
by reducing the luminal pressure on an anastomo-
sis. It did not defunction the faecal stream, however,
and this practice has now been superseded by loop
ileostomy or colostomy if protection is deemed
necessary.
Other methods proposed to decrease the poten-
tial pressure across an anastomosis involve peranal
intubation.3 Again, a urinary catheter has been used
across a low anastomosis, but a custom-designed
silastic stent that sits across a low anastomosis and
has an aperture that allows flushing by a bladder sy-
ringe has been evaluated, with encouraging results.3
The tube or stent is removed at 5–7 days or when
the patient has opened their bowel.
Closure of stomas
Timing of stoma-reversal surgery is important and
often is determined by multiple factors.
Before stoma reversal, most surgeons advocate
confirmation of anastomotic healing by a fluoro-
graphic water-soluble contrast enema. It is recom-
mended that the surgeon performs a digital rectal
examination before referral for a contrast study;
often a soft stricture is encountered and should be
digitally dilated. Care is needed in inserting the soft
rubber enema tube to avoid undue trauma, espe-
cially to a very low anastomosis. Gastrograffin or a
similar agent is then allowed to flow down the tube
to fill the neorectum, and X-ray images are taken.
These X-rays can be taken a few weeks after sur-
gery, thereby allowing the reversal operation to be
planned. If no adjuvant therapy is proposed, then
the patient may be booked for reversal at 6–8  weeks
after their resection, although generally the longer
the time interval (even beyond this), the less diffi-
cult the procedure. The delay allows the adhesions
between the stoma and abdominal wall to mature
to a point where subsequent dissection is safer, with
less peristomal and bowel oedema.
Some surgeons rely on clinical examination
alone to determine whether the anastomosis is in-
tact. A careful digital examination is performed to
feel for an intact join around the circumference of
HEBK001-C15_p228-238.indd 232
the bowel. This may be supplemented by luminal
endoscopy.
If the pathology of the resected specimen is re-
ported as an advanced tumour, adjuvant therapy
may be offered. The timing of adjuvant therapy is
thought to be important, as undue delay from the
original surgery may render adjuvant therapy less
effective. Thus, reversal of a defunctioning stoma
may delay treatment, so many oncologists prefer
to treat before stoma reversal, and the reversal may
have to be deferred for 6 months or longer.
The principles of stoma reversal are similar for
loop ileostomy or colostomy reversal. An incision
is made around the stoma at the interface of the
skin and mucosa. Some surgeons recommend a
transverse elliptical incision a few millimetres away
from the skin mucosa interface, with the ends ta-
pering together at the 3 and 9 o’clock positions to
improve the eventual scar. Once the edge of the
bowel is identified, careful dissection proceeds cir-
cumferentially to free up the adhesions between
the bowel and the abdominal wall. Sharp dissec-
tion is preferred to diathermy, thereby preventing
thermal damage to the bowel. This should be a rel-
atively bloodless plane; if difficulty is encountered
with small bleeding points, it may be that there is
a further layer of tissue still attached to the bowel
wall. The dissection is deepened circumferentially,
separating the bowel from the sheath and muscle
layers, until the abdominal peritoneal cavity is
­entered. Within the peritoneal cavity, the remain-
ing adhesions can be freed, often by sweeping a fin-
ger in the peritoneal cavity deep to the abdominal
wall. This allows delivery of a good length of both
bowel ends through the abdominal wall.
Attention should then be focused on preparing
the bowel for anastomosis. There may be a small
rim of skin remaining on the edges of the bowel,
and this should be excised. Bleeding during this
manoeuvre is a good sign, as it signifies that there
should be a healthy blood supply to the new anasto-
mosis. The ends of a spouted ileostomy should then
be unfolded. Often, as the stoma has been formed
only a few weeks previously, the adhesions may
be flimsy without any undue fibrosis. Sometimes
gentle digital pressure alone is enough to evert the
spout, but on other occasions careful sharp dissec-
tion may be required. This allows the ends of the
bowel to be approximated, assisted by the exist-
ing continuity of the back wall. The bowel is then
08/02/13 5:29 PM

sutured. The authors favour using a 3/0 polydiox-
anone suture with interrupted stitches to form an
end-to-end anastomosis. The first sutures should
be placed at each end of the closure; it can be use-
ful to hold these two tied sutures apart using artery
forceps, thereby facilitating further stitch place-
ment. Further extramucosal stitches are placed and
tied, until the last suture is placed. Careful inspec-
tion of the anastomosis ensures no gaping defects,
and the bowel can then be gently reduced into the
abdominal cavity. If reduction is difficult, it is better
practice to further open the sheath rather than risk
haematoma formation or damaging a new anasto-
mosis by forcing it through a tight gap. Haemostasis
should be checked before fascial closure.
An alternative way of fashioning the anastomo-
sis is to use mechanical stapling instruments. Once
the two limbs of the bowel have been freed, as de-
scribed above, the two limbs of a linear stapler
are inserted into the lumen of the loops of bowel
and the device approximated but not closed. It is
crucial at this point to check that the mesentery
of the bowel is not caught in the stapler, as firing
through this may lead to troublesome bleeding,
with the risk of haematoma formation and bowel
ischaemia. The stapler can then be closed fully
and a final check made that the mesentery is clear.
After firing, the linear stapler device is opened
and removed, and a transverse stapler is applied
perpendicular to the first staple line to seal the
opened bowel ends. A linear stapler for this part
of the technique is no longer recommended, as
anastomotic leakage from the cross-stapling line
has been reported. The excess bowel can then be
removed using a scalpel. Many surgeons recom-
mend re-enforcing the staple line with sutures and
also placing a separate stitch approximately 1 cm
beyond the extent of the first staple line to help
relieve tension at this point, as this is an area re-
ported as being prone to leakage.
Once the bowel has been closed and reduced
into the abdomen, the abdominal wall is closed.
The sheath is sutured with a strong monofila-
ment nylon using either continuous or inter-
rupted sutures. Antiseptic can then be poured
into the cavity, in an effort to reduce the risk of
infection. Interrupted sutures or skin clips can be
used to close the skin, allowing some of the clips
or sutures to be removed easily in the event of a
superficial infection.
HEBK001-C15_p228-238.indd 233
STOMA COMPLICATIONS  233
Due to the risk of postoperative infection, some
surgeons prefer to leave the skin wound open. Some
have advocated a circumferential skin incision at
the skin/mucosa interface and then subsequently a
nylon purse-string to draw the edges together and
an alginate dressing as a plug in the centre. This re-
quires regular dressing changes postoperatively, but
the resulting scar is usually surprisingly neat and
contracts down, with very low infection rates.
STOMA COMPLICATIONS
There are a number of stoma-related complications.
Complications related to temporary defunctioning
stomas may be managed conservatively or tolerated
until reversal, but patients who have a permanent
stoma may require corrective surgery.
Stricture/Retraction
Stricturing of the skin around a stomal orifice may
be associated with a degree of retraction of the bowel.
Minor separation of the mucocutaneous border is
common and managed conservatively with careful as-
sessment to ensure no collection or cellulitis develops.
Subsequent healing by secondary intention may lead
to a degree of scarring and subsequent stricturing.
Dilation of a minor stricture may be successful, but
if this fails surgery may be warranted if the stoma is
permanent and the stricture problematic. Often, this
is straightforward and requires only incision of the
scarred area just away from the orifice, and a small
sliver of the scar tissue is excised. The bowel is then
re-approximated to the skin using absorbable sutures.
A more significant and early retraction may be
seen if there is too much tension on the bowel at the
time of stoma creation. Abscess formation or cellu-
litis may occur in this instance, and a re-laparotomy
may be required. This is often a difficult operation,
with oedema and infection, resulting in friability of
the tissues.
For an ileostomy that gradually retracts and loses
its spout, a local revision may be possible. This in-
volves a circumstomal incision and gentle dissec-
tion of the layers between the bowel and the ab-
dominal wall. Often, once freed circumferentially,
the bowel can be advanced gently and the spout
resutured satisfactorily.
08/02/13 5:29 PM
 234  Intestinal stoma and the role of defunctioning a low anastomosis after anterior resection
Prolapse
Prolapse is more common with a colostomy, par-
ticularly loop colostomy. Local amputation of the
redundant prolapse of an end colostomy with re-
suture of the mucocutaneous junction is a straight-
forward procedure that can be done under local
anaesthetic in an unfit patient. Recurrent prolapse
is common, however. Loop stomas, particularly
loop colostomies, are more prone to prolapse (al-
most always the distal limb) and are solved by sto-
ma closure, provided reversal is safe and feasible. If
reversal is not imminently possible, one option with
a prolapsing loop is to mobilize the bowel circum-
ferentially and then staple off the distal limb, which
is reduced into the peritoneal cavity. The proximal
limb is then refashioned into an end stoma, after
amputating any redundant length.
Herniation
Parastomal herniation is very common, but the
risk of strangulation is low. Patients with hernia-
tion may have leaking bags caused by difficulty in
getting appliances to adhere and seal properly. Vari-
ous flanges and belts are available that may prevent
this problem, but sometimes surgical intervention
is r­ equired.
Several options have been evaluated to repair
these herniae, with variable success rates report-
ed. All of them have a high incidence of hernia
recurrence, and patients should be consented
accordingly. Peristomal local mobilization, sac
herniotomy and closure of the sheath with non-
absorbable sutures is probably easiest but also
prone to the highest failure rate. A better repair
may be achieved by making a medial incision
away from the stoma site and approaching the sac
anterior to the abdominal wall musculature. The
mucocutaneous junction is kept intact and the
stoma covered during this operation. Once the
sac is reduced, the defect can be closed with non-
absorbable sutures and a synthetic mesh used to
reinforce the area. Using synthetic mesh in this
way still carries a risk of infection, but newer al-
ternatives with collagen-based biological mesh
may be helpful in this scenario. Biological meshes
are expensive, however, and long-term follow-up
is not currently available.
HEBK001-C15_p228-238.indd 234
Developments in laparoscopic surgery have ex-
tended to laparoscopic parastomal hernia repair.
Laparoscopic ports are introduced and positioned
well away from the stoma orifice, and intra-abdom-
inal reduction of the parastomal contents allows
the placement of synthetic mesh around the bowel.
Procedure-specific meshes have antiadhesion back-
ing layers to minimize adhesion formation. The
mesh can be positioned and fixed into place, and
the ends overlapped to ensure complete encircle-
ment of the bowel where it passes through the ab-
dominal wall.
The other option to repair a parastomal hernia
is to perform a re-laparotomy, take down the origi-
nal stoma, and resite in a new premarked position.
The defect at the original site can be closed with a
strong non-absorbable monofilament suture. Some
surgeons insert a prophylactic biological mesh to
reduce the risk of longer-term hernia recurrence.
EVIDENCE FOR FAECAL DIVERSION
AFTER TOTAL MESORECTAL
EXCISION
Anastomotic leakage following TME is impossible
to prevent completely. Predicting risk and manag-
ing consequences therefore becomes the aim of the
surgeon. Rates of leakage after anterior resection
vary between institutions, but a consistent predic-
tor of an increased risk is the height of the anasto-
mosis from the anal verge.4 Colorectal anastomoses
below the peritoneal reflection, or coloanal anasto-
moses, have clinical leak rates reported in the range
11–37.5 per cent.5 A meta-analysis of defunctioning
stoma versus no stoma following rectal resection
concluded that defunctioning resulted in a lower
leak rate.6 The meta-analysis included data from
four randomized controlled trials (RCTs)5,7–9 and 21
non-randomized studies, with 11 429 patients in to-
tal. Meta-analysis of the RCTs showed a lower clini-
cal anastomotic leak rate and a lower reoperation
rate in the stoma group. In the non-randomized
studies, a lower clinical anastomotic leak rate, lower
reoperation rate and lower mortality rate in the
stoma group was reported.
The strength of available evidence in favour of fae-
cal diversion with proximal ostomy raises the ques-
tions of how best to divert the faecal stream, the likeli-
hood that a defunctioning stoma will be permanent,
08/02/13 5:29 PM
 EVIDENCE FOR FAECAL DIVERSION AFTER TOTAL MESORECTAL EXCISION  235
and the risks specifically associated with a defunction-
ing stoma and with stoma reversal.
Loop Colostomy or Ileostomy?
A systematic review and meta-analysis of RCTs and
observational studies comparing temporary loop
ileostomy and loop colostomy for defunctioning
of colorectal or coloanal anastomoses has reported
findings in support of loop ileostomy.10 Clinically
relevant events were grouped into four study out-
comes:
l general outcome measures: dehydration, wound
infection;
l construction of the stoma outcome measures:
parastomal hernia, stenosis, sepsis, prolapse,
retraction, necrosis, haemorrhage;
l closure of the stoma outcome measures: anasto-
motic leak or fistula, wound infection, occlu-
sion, hernia;
l functioning of the stoma outcome measures:
occlusion, skin irritation.
Five randomized controlled trials and seven ob-
servational studies were included in this analysis.
Overall, the included studies reported on 1529 pa-
tients, just over half of whom (58 per cent) under-
went defunctioning loop ileostomy. Loop ileostomy
had a lower risk of prolapse and sepsis but was as-
sociated with a higher risk of dehydration due to a
high output and intestinal obstruction after stoma
closure. There were no other significant differences.
Included in the analysis was a small randomized
trial from the authors’ institution, which reported
in favour of loop ileostomy versus loop colostomy
after TME surgery, due to fewer abdominal wall
problems (incisional hernia, wound infection) in
the ileostomy group.11
Frequency of Non-Reversal of
Defunctioning Stoma
Although intended to be temporary, a substantial pro-
portion of defunctioning stomas are never reversed
and in effect the loop stoma becomes permanent. The
Dutch Colorectal Cancer Group analysed data from
a TME trial in patients with rectal cancer to identify
factors that limit stoma reversal.12 In total, 924 patients
HEBK001-C15_p228-238.indd 235
with rectal cancer (459 in the radiotherapy group, 465
in the non-radiotherapy group) who underwent a low
anterior resection had a defunctioning stoma in the
prospective randomized TME trial involving a total of
1530 patients. Creation of stomas and time to stoma
reversal were analysed retrospectively by use of mul-
tivariate analysis. In 523 of 924 patients (57 per cent),
a primary stoma (defined as a stoma created at the
time of TME) was constructed after a low anterior
resection. Loop ileostomy was formed in 329 patients
and colostomy in 194 patients. Secondary stoma, de-
fined as any stoma created during a second or follow-
ing procedure after TME, was necessary in 93 of 401
patients (23 per cent). The main reasons for second-
ary stoma formation were anastomotic leakage (n 5
61), abscess, sepsis or peritonitis (n 5 18) and fistula
(n 5 6). The total number of patients who therefore
received a temporary stoma either at initial surgery or
at a secondary stage was 616 of 924 patients (67 per
cent). For stomas that were closed, 97 per cent were
done so within the first postoperative year.
Nineteen per cent of these defunctioning stomas
were never reversed during follow-up. Multivariate
analysis demonstrated that preoperative radiotherapy
was associated significantly with a decreased likeli-
hood of stoma reversal for secondary stomas, but not
for primary stomas. Older age, secondary stoma con-
struction, an end ileostomy or colostomy, any postop-
erative complication and recurrence were identified as
limiting factors for stoma reversal.
The authors concluded that postoperative com-
plications are an important limiting factor for
stoma reversal because, unsurprisingly, after occur-
rence of these complications, patients and surgeons
may be reluctant to reverse a defunctioning stoma.
The most important trial addressing the issue
of outcomes after TME for rectal cancer has been
a Swedish RCT multicentre trial, which reported
6-year follow-up data.7,13 In total, 234 of 821 pa-
tients (28 per cent) undergoing TME were random-
ly assigned to have either a defunctioning stoma
(n 5 116) or no defunctioning stoma (n 5 118). All
patients randomized had a satisfactory anastomosis
with a negative air-test. Strict definition of leakage,
including pelvic abscess, rectovaginal fistula and
late leaks, was adhered to. In the original analysis,
symptomatic anastomotic leakage was present in
12 of 116 patients (10.3 per cent) with a defunc-
tioning stoma versus 33 of 118 patients (28.2 per
cent) without a defunctioning stoma (P , 0.001).7
08/02/13 5:29 PM
 236  Intestinal stoma and the role of defunctioning a low anastomosis after anterior resection
This significant reduction in leak rates was ob-
served irrespective of gender. The requirement for
emergency reoperation was also significantly high-
er in the group with no stoma (30 of 118 patients,
25.4 per cent) compared with the group with a
­defunctioning stoma (10 of 116 patients, 8 per cent)
(P , 0.001). Of great interest was that with meticu-
lous follow-up, 40 per cent of leaks were diagnosed
after discharge from hospital at a median of 24 days
(range 13–172 range). At a median follow-up of
42 months postoperatively, more patients who
started out with no stoma had a stoma (20 of 118
patients v. 16 of 116 patients; P 5 not significant).
At 6-years’ follow-up, 1 patient had died and
the total number of patients with stomas had risen
from 36 to 45.13 The total group was analysed with
regard to the presence of a permanent stoma, the
type of stoma, the time point at which the stoma
was constructed or considered as permanent, and
the reasons for requiring a permanent stoma.
During the study period, 45 of 233 patients (19
per cent) were considered to have a permanent sto-
ma: 25 had an end sigmoid colostomy and 20 a loop
­ileostomy. End colostomies were constructed at a
median of 22 months after TME, predominantly for
anastomotic leakage. Loop ileostomies, performed
either at initial surgery (n 5 12) or secondarily
(n 5 8), were considered as permanent at a medi-
an of 12.5 months after the initial rectal resection.
The reasons for a permanent loop ileostomy were
metastatic disease, unsatisfactory anorectal func-
tion, deterioration in general medical condition,
new non-colorectal cancer, patient’s refusal of fur-
ther surgery, and chronic constipation. The risk of
having a permanent stoma in patients with symp-
tomatic anastomotic leakage was significantly high-
er compared with patients without symptomatic
anastomotic leakage (56 per cent v. 11 per cent).
Both the Dutch TME study and the Swedish RCT
demonstrate the importance of consent at the time
of original TME with regard to the possible perma-
nence of a defunctioning stoma.
Risks and Complications of a
Defunctioning Loop Ileostomy and its
Subsequent Reversal
Most reports on the morbidity of a defunctioning
loop ileostomy, predictors of complications and
HEBK001-C15_p228-238.indd 236
non-closure of stoma, and complication rates fol-
lowing reversal have been retrospective reviews of a
single-institution experience, with variable results.
Chun and colleagues reported 123 patients who
underwent a planned temporary defunctioning
loop ileostomy performed at the time of a low rec-
tal anastomosis.14 The primary outcome measures
were the ileostomy complication rate for the en-
tire spectrum of care, readmission and reoperation
rates to treat ileostomy complications, and subse-
quent closure rate. Of these patients, 64.2 per cent
experienced some form of morbidity during their
care, the biggest group being patients readmitted
for dehydration following ileostomy formation
(11.4 per cent). The ileostomy was closed in 76.4
per cent of patients, with 8.6 per cent requiring a
midline laparotomy (a non-closure rate of 23.6 per
cent, which is higher than in the Dutch and Swedish
groups). The overall ileostomy-related reoperation
rate was 10.4 per cent (2.4 per cent during index
hospitalization, 1.6 per cent at readmission, and
6.4 per cent following ileostomy closure). Obesity
(body mass index $ 30 kg/m2) was associated with
a higher overall ileostomy complication rate and
outpatient complication rate. Age over 65 years and
hypertension increased the risks of high ileostomy
output and dehydration. Obesity and smoking de-
creased the likelihood of ileostomy closure.
Akiyoshi and colleagues considered complica-
tions of stoma closure to evaluate the risks and
benefits of a defunctioning stoma.15 Data were pro-
spectively recorded in 125 consecutive patients who
underwent an elective closure of loop ileostomy
after primary rectal cancer resection. Postopera-
tive complications developed in 21 patients (16.8
per cent), the majority being wound infections;
­ileus and anastomotic bleeding were also reported.
There was no postoperative mortality. Risk factors
for wound infection included male gender and sur-
gical site infection after primary surgery. The mean
length of postoperative hospital stay was signifi-
cantly longer in patients with complications than in
patients without complications.
Luglio and colleagues reported the rate of com-
plications after ileostomy reversal in 944 patients
using standardized definitions and perioperative
variables and 30-day outcomes.16 Anastomotic
technique for reversal varied (sutured fold-over,
49.4 per cent; stapled, 33.4 per cent; hand-sewn end
to end, 17.3 per cent). Patients who had sutured
08/02/13 5:29 PM

closure had longer operative times, increased times
to bowel movement and initiation of soft diet, and
longer time to discharge, but no difference in other
variables. Overall, complications occurred in 203
patients (21.5 per cent), including 45 patients (4.8
per cent) who experienced a major complication.
There was no post-reversal mortality.
D’Haeninck and colleagues analysed 197 consec-
utive patients who underwent closure of a defunc-
tioning loop ileostomy.17 Again, the method of clo-
sure varied (transverse closure of enterotomy, 75.6
per cent; segmental enterectomy with hand-sewn
end-to-end anastomosis, 13.2 per cent; stapled side-
to-side anastomosis, 11.2 per cent). Overall postop-
erative morbidity and mortality were 32.0 per cent
and 0.5 per cent, respectively. The surgical complica-
tion rate was 30.5 per cent, including prolonged il-
eus (11.2 per cent), small bowel obstruction (4.1 per
cent), anastomotic leak (3.0 per cent) and wound
infection (4.6 per cent). Surgical complications were
more frequent in male patients. Prolonged ileus was
more frequent when the interval to stoma reversal
exceeded 12 weeks. The incidence of complications
was not influenced by the closure technique. Nine-
teen patients (9.6 per cent) required reoperation for
anastomotic leak, wound infection, small bowel ob-
struction or repair of an incisional hernia.
The complications following closure of a loop
ileostomy are more frequent in male patients
who are obese. There seems to be no significant
difference between whether the closure is sutured
or stapled. Although these risks should be borne
in mind at the time of stoma construction, the
risks are offset by the higher risks of anastomotic
leakage following TME when not defunctioned,
as documented in the Swedish study.7,13 Ideally,
informed consent for TME should include dis-
cussions that specifically pertain to stoma-related
complications.
CONCLUSION
All colorectal anastomoses are at risk of leakage; the
nearer the anastomosis to the anal verge, the higher
the risk. A defunctioning stoma reduces the con-
sequences (and perhaps the incidence) of leakage
and reduces the requirement for emergency reop-
eration. Nevertheless, a stoma has complications at
formation, in situ and at reversal, which should be
HEBK001-C15_p228-238.indd 237
References  237
borne in mind. Attention to detail and awareness
of the risks and benefits favours consideration of
routine defunctioning for all coloanal anastomoses
after TME surgery.
References
  1. Moran BJ, Heald RJ. Risk factors for and manage-
ment of anastomotic leakage in rectal surgery.
Colorectal Dis 2001; 3: 135–7.
  2. Cartmell MT, Jones OM, Moran BJ, Cecil TD. A
defunctioning stoma significantly prolongs the length
of stay in laparoscopic colorectal resections. Surg
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  3. Amin AI, Ramalingam T, Sexton R, Heald RJ,
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10. Rondelli F, Reboldi P, Rulli A, et al. Loop ileostomy versus
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11. Edwards DP, Leppington-Clarke A, Sexton R, Heald
RJ, Moran BJ. Stoma-related complications are more
frequent after transverse colostomy than loop ileos-
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2001; 88: 360–3.
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08/02/13 5:29 PM

Quality of life in patients undergoing
abdominoperineal excision and anterior
resection for rectal cancer
Peter How and Kandiah Chandrakumaran
Introduction
Since the first description of the abdominoperineal
excision (APE) by W. Ernest Miles in 1908,1 the
surgical management of rectal cancer has evolved
dramatically. Total mesorectal excision (TME), de-
scribed by Heald and colleagues in 1982,2 has since
been recognized as the gold standard treatment for
most patients with rectal cancer. Other advances in
surgical technique, including stapling devices, and
multimodality treatment, have enabled anterior re-
section with sphincter preservation to become fea-
sible for all but very distal rectal cancers. This has
significantly reduced the number of patients bur-
dened with a permanent stoma and the perceived
limitations it imposes. Much of the impetus for this
change was based on the belief that patients have
a better quality of life (QOL) after sphincter pres-
ervation compared with patients with a permanent
colostomy. This view is not supported universally,
however, and remains a topic for debate. Over the
past decade, interest has grown in patient-reported
outcomes. The cultural shift within health care to-
wards a more patient-centred approach has meant
that assessment of treatment efficacy is no longer
confined to classic biomedical indicators such as
survival and mortality. Quality of life has emerged
HEBK001-C16_p239-248.indd 239
16
as an important outcome measure in its own right,
and there is evidence for a positive relationship be-
tween QOL data or some QOL measures and sur-
vival in cancer patients.3
Quality-of-life assessment:
general principles
The term ‘quality of life’ intuitively evokes a sense
of contentment that is influenced by economical,
mental and physical status. Since the World Health
Organization’s (WHO) definition of health in 1948
as ‘a state of complete physical, mental and social
wellbeing and not merely the absence of disease or
infirmity’, health-related quality of life (HRQOL)
has come to represent a multidimensional con-
struct pertaining to four distinct areas of wellbeing:
physical, psychological, emotional and social.
Attempts to measure HRQOL have focused
largely upon these four domains with the use of
specially designed questionnaires. These include,
among others, patient-derived generic and can-
cer-specific modules such as the European Or-
ganization for Research and Treatment of Cancer
(EORTC) Quality of Life Questionnaire – Core 30
(QLQ-C30) (Figure 16.1), EORTC QLQ-CR38,
08/02/13 5:28 PM
 240  QOL in patients undergoing APE and anterior resection

EORTC QLQ-C30 (version 3)

We are interested in some things about you and your health. Please answer all of the
questions yourself by circling the number that best applies to you. There are no "right" or
"wrong" answers. The information that you provide will remain strictly confidential.

Please fill in your initials:

Your birthdate (Day, Month, Year):
Today's date (Day, Month, Year): 31
___________________________________________________________________________
Not at A Quite Very
All Little a Bit Much
  1. Do you have any trouble doing strenuous activities, like 1 2 3 4
carrying a heavy shopping bag or a suitcase?
  2.  Do you have any trouble taking a long walk? 1 2 3 4
  3. Do you have any trouble taking a short walk outside of the 1 2 3 4
house?
  4.  Do you need to stay in bed or a chair during the day? 1 2 3 4
  5. Do you need help with eating, dressing, washing yourself or 1 2 3 4
using the toilet?

During the past week: Not at A Quite Very

All Little a Bit Much
  6. Were you limited in doing either your work or other daily 1 2 3 4
activities?
  7. Were you limited in pursuing your hobbies or other leisure 1 2 3 4
time activities?
  8.  Were you short of breath? 1 2 3 4
  9.  Have you had pain? 1 2 3 4
10.  Did you need to rest? 1 2 3 4
11.  Have you had trouble sleeping? 1 2 3 4
12.  Have you felt weak? 1 2 3 4
13.  Have you lacked appetite? 1 2 3 4
14.  Have you felt nauseated? 1 2 3 4
15.  Have you vomited? 1 2 3 4
Figure 16.1. The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire –
Core 30 (QLQ-C30) questionnaire applicable to all cancers. Questions are grouped into functional scales, e.g. physical
function (questions 1–5), symptom scales, e.g. pain (questions 9 and 19), and single items, e.g. insomnia (question 11).
(Continues)

HEBK001-C16_p239-248.indd 240 08/02/13 5:28 PM

 QUALITY-OF-LIFE ASSESSMENT: GENERAL PRINCIPLES  241

During the past week: Not at A Quite Very

All Little a Bit Much
16.  Have you been constipated? 1 2 3 4
17.  Have you had diarrhoea? 1 2 3 4
18.  Were you tired? 1 2 3 4
19.  Did pain interfere with your daily activities? 1 2 3 4
20. Have you had difficulty in concentrating on things, like 1 2 3 4
reading a newspaper or watching television?
21.  Did you feel tense? 1 2 3 4
22.  Did you worry? 1 2 3 4
23.  Did you feel irritable? 1 2 3 4
24.  Did you feel depressed? 1 2 3 4
25.  Have you had difficulty remembering things? 1 2 3 4
26. Has your physical condition or medical treatment interfered 1 2 3 4
with your family life?
27. Has your physical condition or medical treatment interfered 1 2 3 4
with your social activities?
28. Has your physical condition or medical treatment caused 1 2 3 4
you financial difficulties?

For the following questions please circle the number between 1 and 7 that best applies
to you
29.  How would you rate your overall health during the past week?
   1     2     3     4    5     6     7
Very poor              Excellent
30.  How would you rate your overall quality of life during the past week?
   1      2      3      4     5     6      7
Very poor              Excellent
Figure 16.1. (Continued).

EORTC QLQ-CR29, short form 36 (SF-36), SF-
12, Functional Assessment of Cancer Therapy –
Colorectal (FACT-C) and Functional Assessment
of Cancer Therapy – General (FACT-G). Despite
variation in content and format, certain principles
and concepts remain central to all of these ques-
tionnaires, such as validity (measuring what it is
intended to measure), reliability (measuring with
sufficient precision), sensitivity (ability to detect
changes), reproducibility (cross-cultural), sim-
plicity (enabling self-administration), and easily
interpretable (attaching clinical relevance). Fur-
thermore, the questionnaires are intended to focus
on dimensions that are influenced by health and
can be quantified accurately and appropriately, ac-
cording to its component indicators.4

HEBK001-C16_p239-248.indd 241 08/02/13 5:28 PM

 242  QOL in patients undergoing APE and anterior resection
APE, abdominoperineal excision; LAR, low anterior resection.
Quality of life and the
preoperative pathway
Although much of the literature regarding QOL in
patients with rectal cancer focuses on the effects of
surgery, most clinicians agree that appropriate sup-
port and counselling are vitally important from the
time of diagnosis. The preoperative (pre-cancer re-
section) patient pathway is increasingly a compli-
cated one, often encompassing multimodality treat-
ment, restaging and, in some cases, surgery – all of
which impact heavily upon QOL (Figure 16.2). Pre-
operative baseline QOL scores have been highlight-
ed as prognostic indicators, and so it is important
to provide support at an early stage. This should in-
clude stoma counselling, sex counselling, and coun-
selling about potential faecal incontinence.
Stoma Counselling
Often the most difficult and psychologically de-
manding hurdle to negotiate regarding rectal can-
cer surgery is the concept of a permanent stoma. It
is common to encounter patients for whom such
an idea is untenable. Retrospective studies show
that patients who have access to stoma counselling
before surgery enjoy a better quality of life postop-
eratively.5 In addition, accurate preoperative stoma
siting and counselling by a stomatherapist helps to
improve outcome in such patients.6
Currently, as befits a patient-tailored approach,
there are no national guidelines pertaining to stoma
HEBK001-C16_p239-248.indd 242
Figure 16.2. Quality of life after
surgery.
counselling. It is common practice, however, to first
establish the patient’s understanding of what a sto-
ma is, followed by the introduction of a ‘starter pack’.
This pack contains basic anatomical and functional
information regarding what to expect both before
and after surgery. It also includes stoma bags and re-
lated accessories to help prepare the patient, and their
partner and family, for future daily maintenance.
Education of the patient’s relatives and carers is
beneficial and worthwhile. Up to half of patients
(and their relatives) with an ileostomy and 30 per
cent of patients with a colostomy have expressed
dissatisfaction at the level of information they have
received.7 Furthermore, up to 60 per cent of pa-
tients are poorly informed about stoma irrigation
techniques,8 despite good evidence for its effective-
ness in achieving faecal continence in patients with
end colostomies.9 In addition, a greater proportion
of patients are unhappy with their degree of par-
ticipation within the decision-making process. It is
clear that although the majority of patients speak
highly of their stoma counselling experiences, there
is a need for continually assessing and modifying
this service, with the aim of improving general
standards of quality of care.
Sex Counselling
Sexual dysfunction remains one of the more long-
lasting side effects of pelvic cancer treatment. Sexu-
al problems are associated with both poor physical
health and emotional distress10 and are considered
08/02/13 5:28 PM
 QUALITY-OF-LIFE OUTCOMES FOLLOWING SURGERY FOR RECTAL CANCER  243
to be a major determinant of global QOL. Despite
the high risk of sexual dysfunction following rectal
cancer surgery, sex counselling remains very much
on the periphery of mainstream care.
It has been suggested that an effective way to im-
plement appropriate sex counselling is to provide
routine screening and counselling for QOL issues
related to cancer treatment. It is proposed that one
person within the colorectal multidisciplinary team
should be assigned the role of assessing and triaging
patients for quality of life problems.11 This could be
conducted via a brief 20- to 30-min interview cen-
tred upon validated questionnaires, which may be
productive for clinical as well as research purposes.
Sex counselling should include educating and
warning patients about potential sexual problems
arising from cancer treatment, helping patients
overcome specific sexual problems (which may oc-
cur before surgery as a result of stress or neoadju-
vant therapy), and preparing patients for physical
changes that may adversely affect body image.12
Faecal Incontinence Counselling
For patients looking to avoid a permanent stoma,
many pay the price in terms of poor functional
outcome, i.e. faecal incontinence. This is particu-
larly true for patients with mid- and lower rectal
tumours, where the closer the anastomosis to the
anal canal, the poorer the functional outcome.
Many patients prefer low anterior resection to APE,
even if low anterior resection involves a risk of in-
continence on a daily basis.13 Faecal incontinence
rates have been reported to be as high as 61.5 per
cent at 5 years following preoperative radiotherapy
and TME.14 The potential need for sanitary towels
and incontinence pads on a permanent basis com-
bined with perianal excoriation is something that
all patients undergoing restorative surgery should
be made aware of. The aim is not to discourage
patients before surgery but to provide realistic ex-
pectations of their likely postoperative quality of
life. The possibility of long-term medication to
help control symptoms and the option of further
surgery as definitive treatment should also be made
clear to give the patient an appropriate perspective
on future events. Knowing that there are options if
problems are encountered can help pre-empt fear
and negativity in the lead-up to surgery and pro-
HEBK001-C16_p239-248.indd 243
mote a more positive outlook on the future. Unfor-
tunately, precise risks of dysfunction have not been
well documented, although research is ongoing.
Quality-of-life outcomes
following surgery for
rectal cancer
The primary objective in managing rectal cancer is
achieving satisfactory oncological clearance while
maintaining QOL acceptable to the patient. Although
much interest surrounds comparative QOL data be-
tween anterior resection and abdominoperineal ex-
cision, it is pertinent that there never has been, and
now unlikely ever to be, a randomized controlled trial
of APE compared with low anterior resection. Thus,
comparative studies are difficult to interpret, and it is
beneficial to look at aspects of QOL in the individual
procedures to determine how each impacts upon
QOL. It is also worth noting that patients treated
with APE will have lower, more advanced tumours,
and a higher percentage will receive neoadjuvant
therapy,15 making direct comparisons with anterior
resection more complex. Anterior resection has long
been associated with superior oncological outcomes
compared with APE,16 and a similar assumption is
often made regarding QOL. In the following section,
QOL outcomes following anterior resection and
APE with regards to function and symptomatology
are outlined. The results are interpreted to identify
major determinants for good and poor outcomes in
order to optimize treatment policy.
Functioning Scores
Physical functioning has been shown to be better
following anterior resection compared with APE
in comparative studies.8,17 These findings are in
keeping with a meta-analysis of several compara-
tive studies, demonstrating statistically significantly
higher physical function within the anterior resec-
tion group that also extends to patients with low
rectal cancer.18 This is perhaps not surprising given
the physical limitations imposed by a permanent
stoma on being able to perform day-to-day tasks
independently.
Good agreement is generally observed between
physical and role functions, and it is tempting to
08/02/13 5:28 PM
 244  QOL in patients undergoing APE and anterior resection
speculate that if patients undergoing APE are phys-
ically limited by their stoma, then everyday work
and leisure activities (role) may be affected adverse-
ly. Support for this theory comes from observations
that QOL scores improve upon stoma reversal.19
This is not always a true reflection of functional
status, however, as significant improvement in role
functioning has been reported despite severe diar-
rhoea following stoma reversal.8 Indeed, despite
significant improvements in body image and leisure
activities, stoma reversal has not always resulted in
improved QOL, while significant worsening of gas-
trointestinal problems may persist for up to a year
following surgery.20
Interestingly, consistent data suggest equiva-
lent8,21 or better emotional and cognitive function
in patients undergoing APE.18 Reasons for this
may include the definitive nature of the surgery,
whereby the patient feels that by removing both the
rectum and anus, there is less chance of recurrence
and no further invasive surveillance is required per
rectum. Patients undergoing anterior resection, on
the other hand, remain troubled by the possibility
of recurrence and further surgery.
Although there is general agreement that fatigue,
pain, nausea and dyspnoea are comparable between
anterior resection and APE, there is conflicting evi-
dence regarding gastrointestinal tract symptoma-
tology. Much of the earlier literature within the
TME era that reported inferior global QOL scores
in patients undergoing APE demonstrated higher
levels of gastrointestinal dysfunction (constipation,
diarrhoea) compared with patients undergoing low
anterior resection, including defecation problems.8
More recent studies, however, have demonstrated
no differences in either global QOL or gastrointes-
tinal dysfunction between the two groups,21 with
some reporting higher scores for gastrointestinal
dysfunction in the anterior resection group.17
It is difficult to explain these differences given
that many of these studies employed similar meth-
ods using identical questionnaires. As patient de-
mographics, tumour stage and follow-up time are
well documented and broadly comparable, other
factors should be considered. One reason may be
due to the improved level and intensity of preop-
erative stoma counselling. Within the UK, it is now
common for multidisciplinary teams to have both
colorectal nurse specialists (offering general sup-
port and guidance) and stoma care nurses (offer-
HEBK001-C16_p239-248.indd 244
ing specific stoma counselling), reflecting increased
specialization within nursing services. The impor-
tance of this is highlighted by the fact that stoma-
related complications often do not impact upon
how patients perceive their quality of care com-
pared with the amount of information they receive,
participation in decision-making and opportunity
to discuss sexual matters.22 It would be reasonable
to extrapolate this towards how they regard their
QOL.
Alternatively, equivalent results may be a result
of adaptation or response shift, whereby patients
who have survived life-threatening disease appear
to have new internal standards and are more willing
to tolerate the adverse effects of either surgery, i.e.
having a stoma or incontinence. Such a phenom-
enon may also account for comparable QOL scores
observed both pre- and postoperatively in previ-
ously reported and emerging studies.23
Despite improvements in APE global QOL scores,
it is notable that body image is consistently report-
ed to be higher in patients undergoing anterior
resection, although this is not always statistically
significant. Unlike functional scores, this aspect of
rectal cancer surgery appears resistant to any form
of counselling or psychotherapy and is probably a
contributing factor to the inferior sexual function
observed in patients undergoing APE. Interestingly,
body image is significantly impaired in both sexes,
although women demonstrate a relatively lower sex
drive preoperatively, while in the months following
surgery both men and women are affected negative-
ly by a stoma.24 Such studies have called for greater
attention to be paid to preoperative patient coun-
selling with regard to body image and sexuality.
Sexual Dysfunction Following
Rectal Cancer Surgery
One critical aspect of TME, introduced by Heald
and colleagues, is the meticulous preservation of
the pelvic autonomic nerves, which has resulted in
a reduction in sexual dysfunction following rectal
cancer surgery. Sexual dysfunction continues to
be a major complication following anterior resec-
tion, and APE however, with rates varying between
10 per cent and 60 per cent.25 This may be com-
pounded further by neoadjuvant and adjuvant ra-
diotherapy.26
08/02/13 5:28 PM
 Quality-of-life outcomes following surgery for rectal cancer  245
There is widespread agreement within the lit-
erature that APE carries a higher risk of sexual
dysfunction than anterior resection. One feature
of this is altered body image associated with
a permanent colostomy, described previously.
Other reasons accounting for this, particularly
regarding male sexual dysfunction, are a higher
proportion of T4 tumours, lower rectal tumours,
radiotherapy, comorbidity, and increased risk of
nerve damage during surgery given the extent of
the dissection and significant alteration in pelvic
anatomy.27 With respect to physiological sexual
dysfunction, it is perhaps best to focus on com-
bined genitourinary function as a reflection of
autonomic nerve preservation. Enker and col-
leagues demonstrated that 57 per cent of patients
undergoing APE compared with 85 per cent of
patients undergoing restorative surgery were able
to maintain both urinary and sexual function.28
Similar emerging data on sexual function from
our own multicentre prospective study echo
these sentiments, despite global QOL scores re-
maining broadly equivalent.
Factors Affecting Functional Outcome
Following Anterior Resection
Level of anastomosis
Functional outcome is thought to be worse the
lower the anastomosis because of smaller reservoir
volume. It has been demonstrated that lower anas-
tomotic level tends towards increased frequency of
incontinence for solid stool and gas.21 These find-
ings correlate well with the demonstration of more
frequent or painful bowel movements in patients
undergoing low anterior resection.8 Interestingly, a
higher composite score for incontinence is not al-
ways reflected in QOL scores between patients with
high and low anastomosis. This may be a reflection
of the response shift phenomenon described earlier,
whereby patients undergoing low anterior resection
have lower expectations of their outcome compared
with patients undergoing high anterior resection. It
is not always correct, therefore, to assume that gas-
trointestinal symptomatology, depending on the
level of the anastomosis, will affect QOL, although
this does remain a possible reason for the observed
variability between studies comparing patients with
and without a stoma.
HEBK001-C16_p239-248.indd 245
Neorectal reservoir
If restorative surgery is possible for low rectal tu-
mours, many surgeons perform a circular transanal
double-stapled low colorectal or coloanal anasto-
mosis, commonly without a pouch. Such patients
often end up having poor function, particularly
with regard to continence due to impaired neorec-
tal function. Development of the colonic J-pouch
anal anastomosis29,30 has been reported to reduce
stool frequency and defecation urgency.31 System-
atic reviews and meta-analyses of randomized con-
trolled trials have reported improved function with
colonic J-pouch anal anastomosis compared with
a conventional straight coloanal anastomosis,32–35
suggesting better QOL scores for colonic J-pouch
anal anastomosis.36
Despite good evidence for the J-pouch improv-
ing outcomes and QOL, the technique is not always
possible. For example, a very narrow pelvis, a fatty
mesentery or restrictions in length may mean this
technique is impossible to perform in certain pa-
tients. Encouragingly, similar functional outcomes
have been observed in side-to-end anastomosis,37
which is technically easier to perform and is a useful
alternative when there is inadequate bowel length
for a J-pouch.
As an additional option, the technique of colo-
plasty has been developed with a similar aim of
improving outcome and QOL. Coloplasty follows
the principles of pyloroplasty in that a longitudi-
nal incision is closed transversely and the recon-
struction is completed by a stapled anastomosis or
a hand-sewn end-to-end pouch anal anastomosis.
Quality-of-life studies based on SF-36 have demon-
strated better scores for coloplasty compared with
straight anastomosis, including fewer bowel move-
ments and less antidiarrhoeal medication,38 and
equivalent functional outcome to colonic J-pouch
anal anastomosis and side-to-end anastomosis.39,40
Radiotherapy
There is no doubt that the systemic effects of ra-
diotherapy have a significant detrimental effect on
QOL. Prospective studies using EORTC modules
assessing the effects of neoadjuvant radiotherapy
have shown significantly increased scores for diar-
rhoea, fatigue and appetite loss and worse outcomes
for physical function, social function and global
QOL.41 As QOL scores tend to return to pretreat-
ment levels 4–6 weeks after radiotherapy, however,
08/02/13 5:28 PM
 246  QOL in patients undergoing APE and anterior resection
it is perhaps more important to focus upon long-
term local effects.
Radiotherapy, by way of fibrosis, is purported to
reduce compliance of the rectum, resulting in re-
duced reservoir function. It is also thought that ra-
diotherapy-induced fibrosis affecting the myenteric
plexus prevents adequate closure of the anal canal
in its resting state.
Preoperative radiotherapy, whether long or short
course, has been associated with higher levels of fre-
quency and urgency42 and faecal incontinence14,43,44
when assessed postoperatively in randomized con-
trolled trial settings. A systematic review outlined
similar late adverse effects related to radiotherapy
in the treatment of rectal cancer.45
In addition, daily urinary incontinence has been
reported more frequently after radiotherapy, with a
similar adverse effect on social function.43
The benefits of radiotherapy in reducing local re-
currence have to be balanced against the adverse ef-
fects of radiotherapy on bowel function and QOL.46
The most effective strategy to help improve this as-
pect of patient care would appear to lie in careful
patient selection, so that substantial overtreatment
is avoided.
Low rectal cancer surgery
and quality of life: the heart
of the matter
Given that patients with high and mid-rectal tu-
mours routinely undergo restorative surgery (ex-
cept for patients with poor preoperative function),
it is patients with distal rectal cancer (commonly
defined as within 6 cm of the anal verge) who
present the greatest challenge. This includes the
technical challenges of low rectal cancer and the
difficult decision as to whether to perform ante-
rior resection or APE. Increasingly, it is oncologi-
cally feasible to perform either operation; provided
the patient has been continent before the onset of
the cancer and has no strong objections to a per-
manent stoma, the surgeon must decide which
operation will give the best outcome. Techniques
such as anal manometry have been suggested as
reliable predictors of functional outcome, but evi-
dence for this is inconclusive. Given that low rec-
tal cancers are associated with more postoperative
complications and poorer anorectal and sexual
HEBK001-C16_p239-248.indd 246
function47 and that patients with low rectal cancer
have worse QOL than patients with upper or mid-
dle rectal cancers, further information on surgical
options and outcomes in low rectal cancer would
be helpful. Ideally, good-quality prospectively col-
lected QOL data using established questionnaires
would represent progress on this front, and this is
currently in progress. There is an increasing interest
in comparative QOL for APE and anterior resection
for low rectal cancer, with several studies reporting
interesting conclusions. Among these are better
sexual functioning scores observed in patients un-
dergoing APE (both genders) and worse scores for
gastrointestinal symptoms in patients undergoing
anterior resection.17 This has not impacted on the
general trend of equivalent overall QOL outcomes,
however (albeit with certain specific differences),
even within larger studies.48 More recent studies re-
porting inferior QOL in patients with permanent
stomas remain fewer and are generally hampered
by smaller sample sizes.49 Although it is difficult to
draw firm conclusions in the face of such contradic-
tory evidence, there are variations between reported
studies including, in some, a lack of preoperative
QOL data, single institution involvement and re-
sponse bias. In addition, length of follow-up is im-
portant given that patients undergoing restorative
surgery commonly suffer from anterior resection
syndrome (frequency, urgency, stool fragmentation,
incontinence), which may persist beyond 1 year.50
Furthermore, there is often little or no information
regarding the surgical technique (e.g. level and type
of anastomosis, presence of pouch) or the level of
preoperative counselling, factors known to influ-
ence outcome.
Conclusion
Interest in QOL outcomes has grown significantly
over recent years and is likely to continue, in keep-
ing with growing importance placed on patient-
reported outcome measures. The remit of the sur-
geon is no longer only to remove cancer, but also to
ensure the best possible outcome in keeping with
the patient’s wishes and beliefs. This has important
implications regarding the selection of patients
for multimodality treatment and technical factors
relating to surgical technique. Although every pa-
tient should be considered on an individual basis,
08/02/13 5:28 PM

i­ nformation, advice and counselling must be cen-
tred on a strong collective evidence base. Long-term
QOL prospective studies using internationally vali-
dated questionnaires currently represent the most
assured way of achieving this.
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