Short-term outcomes of the modified extralevator abdominoperineal resection for low rectal cancer (with videos)



Extralevator abdominoperineal resection had oncologic superiority with reduced local recurrence and improving survival rates. However, extended perineal resection resulted in complicated perineal reconstructions. Therefore, a new surgical technique to overcome previous limitations is required. This study aims to demonstrate a surgical procedure and outcomes of the modified extralevator abdominoperineal resection, which satisfies both an extended cylindrical resection and a convenient perineal wound closure by modification of the surgical dissection plane.


From September 2011 to February 2014, 12 consecutive patients (five males and seven females) who underwent the modified extralevator abdominoperineal resection for low rectal cancer were evaluated. Intraoperative and postoperative outcomes were assessed. Pathologic outcomes were evaluated for the oncologic results.


The mean age was 55.3 ± 15.1 years, and body mass index was 21.8 ± 3.1 kg/m2. Ten patients (83.3 %) received preoperative chemoradiotherapy. The operations were performed by five cases of laparoscopic surgery, six cases of open surgery and one case of robotic surgery. The mean operation time was 258.8 ± 58.0 min. There were no conversions and no tumor perforations. Days to first soft diet was 4.7 ± 3.4 days, and the mean hospital stay was 11.2 ± 4.7 days. Postoperative complications were two cases of grade I, two cases of grade II and one case of grade III. There was one patient (8.3 %) with a positive circumferential resection margin, and there was one case of local recurrence.


The modified extralevator abdominoperineal resection was feasible and safe for patients with low rectal cancer with extended perineal dissection and convenient direct wound closure.

This is a preview of subscription content, log in to check access.

Access options

Buy single article

Instant unlimited access to the full article PDF.

US$ 39.95

Price includes VAT for USA

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5


  1. 1.

    Campos FG, Habr-Gama A, Nahas SC, Perez RO (2012) Abdominoperineal excision: evolution of a centenary operation. Dis Colon Rectum 55(8):844–853. doi:10.1097/DCR.0b013e31825ab0f7

  2. 2.

    Heald RJ, Husband EM, Ryall RD (1982) The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg 69(10):613–616

  3. 3.

    Wibe A, Syse A, Andersen E, Tretli S, Myrvold HE, Soreide O (2004) Oncological outcomes after total mesorectal excision for cure for cancer of the lower rectum: anterior vs. abdominoperineal resection. Dis Colon Rectum 47(1):48–58. doi:10.1007/s10350-003-0012-y

  4. 4.

    Marr R, Birbeck K, Garvican J, Macklin CP, Tiffin NJ, Parsons WJ, Dixon MF, Mapstone NP, Sebag-Montefiore D, Scott N, Johnston D, Sagar P, Finan P, Quirke P (2005) The modern abdominoperineal excision: the next challenge after total mesorectal excision. Ann Surg 242(1):74–82

  5. 5.

    Nagtegaal ID, van de Velde CJ, Marijnen CA, van Krieken JH, Quirke P (2005) Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol 23(36):9257–9264. doi:10.1200/jco.2005.02.9231

  6. 6.

    Eriksen MT, Wibe A, Syse A, Haffner J, Wiig JN (2004) Inadvertent perforation during rectal cancer resection in Norway. Br J Surg 91(2):210–216. doi:10.1002/bjs.4390

  7. 7.

    Bebenek M (2009) Abdominosacral amputation of the rectum for low rectal cancers: ten years of experience. Ann Surg Oncol 16(8):2211–2217. doi:10.1245/s10434-009-0517-2

  8. 8.

    Holm T, Ljung A, Haggmark T, Jurell G, Lagergren J (2007) Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg 94(2):232–238. doi:10.1002/bjs.5489

  9. 9.

    West NP, Anderin C, Smith KJ, Holm T, Quirke P (2010) Multicentre experience with extralevator abdominoperineal excision for low rectal cancer. Br J Surg 97(4):588–599. doi:10.1002/bjs.6916

  10. 10.

    West NP, Finan PJ, Anderin C, Lindholm J, Holm T, Quirke P (2008) Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer. J Clin Oncol 26(21):3517–3522. doi:10.1200/jco.2007.14.5961

  11. 11.

    Huang A, Zhao H, Ling T, Quan Y, Zheng M, Feng B (2014) Oncological superiority of extralevator abdominoperineal resection over conventional abdominoperineal resection: a meta-analysis. Int J Colorectal Dis 29(3):321–327. doi:10.1007/s00384-013-1794-6

  12. 12.

    Stelzner S, Koehler C, Stelzer J, Sims A, Witzigmann H (2011) Extended abdominoperineal excision vs. standard abdominoperineal excision in rectal cancer—a systematic overview. Int J Colorectal Dis 26(10):1227–1240. doi:10.1007/s00384-011-1235-3

  13. 13.

    Artioukh DY, Smith RA, Gokul K (2007) Risk factors for impaired healing of the perineal wound after abdominoperineal resection of rectum for carcinoma. Colorectal Dis 9(4):362–367. doi:10.1111/j.1463-1318.2006.01159.x

  14. 14.

    Christensen HK, Nerstrom P, Tei T, Laurberg S (2011) Perineal repair after extralevator abdominoperineal excision for low rectal cancer. Dis Colon Rectum 54(6):711–717. doi:10.1007/DCR.0b013e3182163c89

  15. 15.

    Sinna R, Alharbi M, Assaf N, Perignon D, Qassemyar Q, Gianfermi M, Deguines JB, Regimbeau JM, Mauvais F (2013) Management of the perineal wound after abdominoperineal resection. J Visc Surg 150(1):9–18. doi:10.1016/j.jviscsurg.2013.02.001

  16. 16.

    Nisar PJ, Scott HJ (2009) Myocutaneous flap reconstruction of the pelvis after abdominoperineal excision. Colorectal Dis 11(8):806–816. doi:10.1111/j.1463-1318.2008.01743.x

  17. 17.

    Marshall MJ, Smart NJ, Daniels IR (2012) Biologic meshes in perineal reconstruction following extra-levator abdominoperineal excision (elAPE). Colorectal Dis 14(Suppl 3):12–18. doi:10.1111/codi.12044

  18. 18.

    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213

  19. 19.

    Edge S, Byrd DR, Comptom CC (2010) AJCC cancer staging manual, 7th edn. Springer, New York

  20. 20.

    Bebenek M, Wojnar A (2009) Infralevator lymphatic drainage of low-rectal cancers: preliminary results. Ann Surg Oncol 16(4):887–892. doi:10.1245/s10434-009-0324-9

  21. 21.

    El-Gazzaz G, Kiran RP, Lavery I (2009) Wound complications in rectal cancer patients undergoing primary closure of the perineal wound after abdominoperineal resection. Dis Colon Rectum 52(12):1962–1966. doi:10.1007/DCR.0b013e3181b71ef9

  22. 22.

    Butt HZ, Salem MK, Vijaynagar B, Chaudhri S, Singh B (2013) Perineal reconstruction after extra-levator abdominoperineal excision (eLAPE): a systematic review. Int J Colorectal Dis 28(11):1459–1468. doi:10.1007/s00384-013-1660-6

  23. 23.

    Christian CK, Kwaan MR, Betensky RA, Breen EM, Zinner MJ, Bleday R (2005) Risk factors for perineal wound complications following abdominoperineal resection. Dis Colon Rectum 48(1):43–48

  24. 24.

    So JB, Palmer MT, Shellito PC (1997) Postoperative perineal hernia. Dis Colon Rectum 40(8):954–957

  25. 25.

    Marijnen CA, Kapiteijn E, van de Velde CJ, Martijn H, Steup WH, Wiggers T, Kranenbarg EK, Leer JW (2002) Acute side effects and complications after short-term preoperative radiotherapy combined with total mesorectal excision in primary rectal cancer: report of a multicenter randomized trial. J Clin Oncol 20(3):817–825

  26. 26.

    Bullard KM, Trudel JL, Baxter NN, Rothenberger DA (2005) Primary perineal wound closure after preoperative radiotherapy and abdominoperineal resection has a high incidence of wound failure. Dis Colon Rectum 48(3):438–443. doi:10.1007/s10350-004-0827-1

  27. 27.

    den Dulk M, Marijnen CA, Putter H, Rutten HJ, Beets GL, Wiggers T, Nagtegaal ID, van de Velde CJ (2007) Risk factors for adverse outcome in patients with rectal cancer treated with an abdominoperineal resection in the total mesorectal excision trial. Ann Surg 246(1):83–90. doi:10.1097/01.sla.0000259432.29056.9d

Download references


The authors thank MiSun Park (professional editor) for the English revision and Dong-Su Jang, MFA (Medical Illustrator, Yonsei University College of Medicine, Department of Research Affairs) for his help with the illustrations of this manuscript.

Author information

Correspondence to Seung Hyuk Baik.

Ethics declarations


Eun Jung Park, Seung Hyuk Baik, Jeonghyun Kang, Hyuk Hur, Byung Soh Min, Kang Young Lee, Nam Kyu Kim, Seung-Kook Sohn have no conflicts of interest or financial ties to disclose.

Additional information

This article was accepted for poster presentation at SAGES 2015 Annual Meeting.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Abdominal phase (WMV 30372 kb)

Perineal phase (WMV 28773 kb)

Perineal wound closure (WMV 26457 kb)

Video 1

Abdominal phase (WMV 30372 kb)

Video 2

Perineal phase (WMV 28773 kb)

Video 3

Perineal wound closure (WMV 26457 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Park, E.J., Baik, S.H., Kang, J. et al. Short-term outcomes of the modified extralevator abdominoperineal resection for low rectal cancer (with videos). Surg Endosc 30, 1672–1682 (2016).

Download citation


  • Rectal cancer
  • Abdominoperineal resection
  • Total mesorectal excision
  • Reconstruction
  • Primary closure