Will the Extra Levator Approach for Low Rectal Cancer Become the New Gold Standard?
Total mesorectal excision (TME) involves radical en bloc excision of the rectum and mesorectum with an intact mesorectal fascia . The object of TME is to achieve a tumour-free circumferential resection margin (CRM) to reduce the risk of local recurrent disease [2, 3]. Worldwide, low rectal cancer is a complex and challenging disease. Patients, in whom the bowel continuity cannot be restored because of a very low-lying rectal tumour or tumour invasion in the anal sphincter complex, are classically treated with an abdominoperineal excision (APE). This operation is associated with higher rates of tumour involvement of the CRM and intraoperative tumour perforations, resulting in a poorer oncological outcome when compared with a (low) anterior resection for more superiorly located rectal tumours [4, 5]. Due to the natural tapering of the mesorectum, the specimen is at great risk to distal coning, which often leads to a nonradical resection. One of the most difficult steps in APE is dissection of the perineal body.
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