Abdominoperineal resection (APR) involves the complete removal of the rectum, anus, and a portion of the sigmoid colon. This operation addresses specific medical conditions affecting the lower digestive tract. A defining outcome of APR surgery is the creation of a permanent colostomy, which reroutes the colon to an opening on the abdominal wall. This opening, known as a stoma, allows for the collection of waste in an external pouch. The procedure requires careful planning and significant recovery time.
Why APR Surgery is Performed
Abdominoperineal resection is performed for rectal cancer, especially when tumors are in the lower rectum, close to the anal sphincter muscles. This proximity often makes it challenging to remove the cancer while preserving sphincter function for bowel control. The surgery ensures clear margins around the tumor, helping prevent cancer recurrence.
APR may also be indicated for anal cancer that has not responded to initial treatments like chemoradiation, or for recurrent anal cancer. Less commonly, it is necessary for severe non-cancerous conditions. These include extensive perianal Crohn’s disease, complex anorectal fistulae unresponsive to other treatments, or severe trauma to the anal and rectal area.
The decision to perform an APR follows a thorough evaluation, considering the tumor’s size, location, and involvement of surrounding tissues. While medical and radiation therapies have reduced its frequency, APR remains an option for appropriate cases. It provides a definitive solution when sphincter-sparing procedures are not feasible or would compromise cancer removal.
Understanding the Surgical Process
Abdominoperineal resection involves two surgical teams working simultaneously. One team operates in the abdominal area, while the other focuses on the perineal region. This dual approach allows for efficient and precise removal of affected structures.
During the abdominal phase, the surgeon mobilizes the sigmoid colon and rectum, dissecting them from surrounding tissues. Blood vessels supplying these sections are divided, and the colon is cut at a healthy point above the diseased area. Lymph nodes in the vicinity are also removed to assess for cancer spread.
The perineal team removes the anus and the remaining portion of the rectum, along with the anal sphincter muscles. This dissection creates a wound between the buttocks and the genitals. Complete removal of all diseased tissue is ensured while minimizing damage to nearby nerves.
After diseased sections are removed, the end of the remaining healthy colon is brought through a surgically created opening in the abdominal wall, usually on the lower left side. The exposed colon tissue is stitched to the skin to form a colostomy. The perineal wound is then closed with sutures.
Preparing for APR Surgery
Preparing for APR surgery involves several steps. Patients undergo comprehensive medical evaluations, including blood tests, imaging scans (CT or MRI), and cardiac assessments. These tests help the medical team understand the patient’s overall health and the extent of the condition.
Consultations with healthcare professionals are part of preparation. Patients meet with their surgeon to discuss procedure details and potential outcomes, and with an anesthesiologist to plan for anesthesia. A wound, ostomy, and continence (WOC) nurse educates the patient about the colostomy and marks the optimal stoma site on the abdomen.
Bowel preparation clears stool from the colon before surgery. This involves a clear liquid diet the day before surgery and a prescribed laxative, such as polyethylene glycol (MiraLAX), along with antibiotics. Patients are also advised to adjust medications like aspirin or NSAIDs, and to cease smoking and alcohol consumption several weeks prior to the operation, as these can affect healing and recovery.
Life After APR Surgery: Recovery and Adjustment
Recovery from APR surgery begins immediately in the hospital, with pain management as a focus. Patients receive pain medication, and nurses monitor surgical wounds, including the abdominal incision and the perineal wound. Early mobilization, such as walking, is encouraged within a day or two to aid recovery.
Living with a permanent colostomy is a key aspect of life after APR. Patients receive comprehensive education from ostomy nurses on how to care for their stoma, including managing the colostomy pouching system. This training covers emptying and changing the pouch, and maintaining healthy skin around the stoma.
Dietary adjustments are necessary following surgery. Initially, patients may start with clear liquids, gradually advancing to soft, low-fiber foods as the bowel recovers. Over several weeks, a more regular diet can be reintroduced, with guidance on managing food choices to prevent issues like constipation or excessive stoma output. Staying well-hydrated is also important.
Adjusting to a new body image and managing a stoma can present emotional and psychological challenges. Support from healthcare providers, support groups, and family can be beneficial during this transition. While the perineal wound may take several months to fully heal and might have some drainage, most individuals can return to many normal activities within six to eight weeks, including light physical activity, with limitations on heavy lifting for a longer period.