Annals of Surgical Oncology

, Volume 17, Issue 5, pp 1357–1358 | Cite as

Anterior Perineal PlanE for Ultralow Anterior Resection of the Rectum (The APPEAR Technique): A Video Demonstration

  • Khalid A. El-GendyEmail author
  • Jamie Murphy
  • Narinder S. Kullar
  • Christopher L. H. Chan
  • Norman S. Williams
Colorectal Cancer



Sphincter-saving rectal resections have become commonplace in the surgical treatment of malignant rectal pathology. However, restoration of gastrointestinal continuity by means of conventional techniques proves technically challenging in cases of very low rectal pathology, with resultant variable requirements for a permanent stoma. The APPEAR procedure (Anterior Perineal PlanE for Ultralow Anterior Resection of the rectum) is a novel sphincter-saving resection technique to restore gastrointestinal continuity in those who would otherwise require a permanent stoma with conventional abdominal resections. It ensures that the distal rectum is excised and the anastomosis is constructed under direct vision while simultaneously preserving the anal sphincter and its somatic nerve supply in their entirety.


This procedure is indicated in the following instances: proven lower-third rectal carcinomas where anatomical restrictions prevent satisfactory rectal dissection and/or transection with a potential inadequate distal clearance margin; ileoanal pouch formation for ulcerative colitis or familial adenomatous polyposis where retained rectal tissue is at risk of future malignancy; short or strictured rectal stumps where pelvic dissection is hazardous and thus prevents restoration of gastrointestinal continuity.


The APPEAR technique is a feasible alternative sphincter-saving procedure to further reduce the requirement of permanent stoma in the treatment for ultralow rectal pathology; however, it is appreciated that a larger study group with long-term follow-up is required. This technique should facilitate laparoscopic rectal resection because large and distal tumors can be dissected and excised through the perineal wound, ensuring adequate distal clearance and the anastomosis constructed under vision at an appropriate level. Furthermore, the requirement for an abdominal incision is avoided, improving cosmesis.


Familial Adenomatous Polyposis Pelvic Floor Musculature External Anal Sphincter Ileal Pouch Perineal Wound 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Supported in part by Bowel and Cancer Research Trust. We thank David Futcher of Flowmotion for his technical skills, which were invaluable for the recording and editing of this video.

Supplementary material

APPEAR Video (WMV 55.4 MB)


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Copyright information

© Society of Surgical Oncology 2009

Authors and Affiliations

  • Khalid A. El-Gendy
    • 1
    Email author
  • Jamie Murphy
    • 1
  • Narinder S. Kullar
    • 1
  • Christopher L. H. Chan
    • 1
  • Norman S. Williams
    • 1
  1. 1.Centre for Academic Surgery, Institute for Cell and Molecular Science, Barts and the LondonQueen Mary’s School of Medicine and Dentistry, University of LondonLondonEngland, UK

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