Abdominoperineal Resection (APR)

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Dr Chong Choon Seng

MBBS | MRCS | Masters in Medicine (Surgery) | FRCS (Edinburgh)

Abdominoperineal resection (APR) is a surgical procedure to remove the anus, rectum, and sigmoid colon. It is often performed to treat specific cancers or other severe conditions affecting these areas. Following the surgery, waste elimination is managed through a permanent colostomy, where the end of the bowel is brought to the surface of the abdomen (stoma).

Indications for Abdominoperineal Resection Indications for Abdominoperineal Resection

Indications for Abdominoperineal Resection

Abdominoperineal resection is advised for severe conditions of the rectum or anus requiring complete tissue removal.

  • Low Rectal Cancer: Tumours located within 5 cm of the anal verge often require removal of the anal sphincter complex to ensure complete cancer treatment.
  • Anal Cancer: This surgery may be necessary when cancer does not respond to initial chemoradiotherapy or recurs after treatment.
  • Inflammatory Bowel Disease: Severe cases of Crohn’s disease or ulcerative colitis that extensively affect the rectum and anus and do not improve with medical treatment may require surgical intervention.

Benefits of Abdominoperineal Resection

Abdominoperineal resection provides several benefits for individuals with severe or complex conditions involving the rectum and anus.

  • Cancer Control: Complete removal of the affected tissue reduces the risk of cancer recurrence and provides a better chance for long-term disease management.
  • Symptom Relief: The surgery relieves pain, bleeding, and bowel dysfunction commonly associated with the underlying condition.
  • Improved Overall Wellbeing: Although adapting to a permanent stoma can be challenging, many patients experience enhanced wellbeing and return to normal activities after recovery.

Surgical Methods

Open Surgery

This traditional method involves an abdominal incision and a perineal incision, providing direct access to the surgical site. It is often chosen for larger tumours or cases requiring extensive tissue removal due to its clear visibility and reach.

Laparoscopic APR

This minimally invasive approach involves several small incisions in the abdomen, along with a perineal incision. It typically results in reduced post-operative pain and faster recovery while maintaining the same cancer treatment standards as open surgery.

Robotic APR

This technique employs robotic assistance for greater precision and enhanced visualisation, especially in the confined space of the pelvis. The surgeon operates robotic arms from a console, allowing for meticulous dissection and improved outcomes in complex cases.

Surgery Preparation

Medical Assessment

A thorough evaluation is conducted, including a physical examination, blood tests, and imaging studies such as CT or MRI scans. Patients with existing medical conditions may also undergo cardiac and respiratory function tests to ensure they are fit for surgery.

Medication Review

Blood-thinning medications are usually discontinued 5–7 days prior to surgery to reduce bleeding risks. Antibiotics may be prescribed to prevent infection, and adjustments may be made to ongoing medications based on the surgical plan.

Bowel Preparation

Patients are typically placed on a clear liquid diet 24–48 hours before surgery. Bowel-cleansing solutions or enemas are used to empty the intestines, ensuring a clean surgical field.

Fasting Guidelines

Patients are advised to stop eating 6–8 hours before surgery and avoid clear fluids for 2 hours before the procedure. The exact timing may vary depending on the anaesthesia requirements.

Step-by-Step Procedure

Anaesthesia Administration

The procedure begins with general anaesthesia to ensure the patient is fully unconscious and pain-free. The patient is positioned appropriately for optimal surgical access, and prophylactic antibiotics are administered intravenously to minimise infection risk.

Abdominal Access

The surgeon accesses the abdominal cavity using either open or laparoscopic techniques. The sigmoid colon and rectum are carefully mobilised, and associated blood vessels are tied off to ensure safe removal of the affected tissue.

Pelvic Dissection

Precise dissection is performed to separate the rectum from surrounding structures, such as the bladder, prostate (in men), or uterus (in women). This meticulous process continues down to the pelvic floor to ensure complete removal of the diseased tissue.

Perineal Incision and Tissue Removal

An incision is made around the anus, allowing for the removal of the anal canal, sphincter complex, and any attached tissue. The affected specimen is then extracted through the perineal incision.

Colostomy Creation

The surgeon creates a permanent stoma by bringing the remaining portion of the colon through a pre-marked site on the abdominal wall. This opening serves as the new pathway for waste elimination.

Wound Closure

The perineal wound is carefully closed, often with drainage tubes in place to prevent fluid build-up. The abdominal incisions are then sutured or stapled to complete the procedure.

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Post-Surgical Care and Recovery

  • Immediate Post-operative Care: After surgery, patients are closely monitored in a recovery area to ensure stable vital signs and manage pain effectively. Stoma function is assessed, and intravenous fluids are provided to maintain hydration. Pain relief is tailored to individual needs, using medications as required.
  • Recovery and Stoma Care: Patients are encouraged to start moving within 24 hours to improve circulation and reduce the risk of blood clots. Stoma care education begins early to help patients gain confidence in managing their colostomy. Diet is gradually reintroduced, starting with clear liquids and progressing to solid foods as tolerated. Drains are removed once fluid output decreases to minimal levels.
  • Long-term Recovery: Full recovery generally takes 6–8 weeks, during which patients adapt to life with a stoma. Regular follow-up appointments monitor surgical healing, assess overall recovery, and check for signs of cancer recurrence or complications.

Potential Risks and Complications

Abdominoperineal resection (APR) carries potential risks, including bleeding, infection, and delayed wound healing, particularly in the perineal region. Nerve damage during the procedure may lead to sexual dysfunction or urinary difficulties. Specific stoma-related complications, such as parastomal hernia, stoma retraction, or prolapse, can also occur. Some patients may experience sensations of a “phantom rectum” or chronic perineal pain following the surgery.

Frequently Asked Questions

How will I manage physical activities with a stoma?

After recovery, most physical activities, including swimming, sports, and exercise, can be resumed. Support garments and stoma protection, such as belts or covers, ensure comfort and security.

What dietary modifications are needed with a colostomy?

Initially, a low-fibre diet is recommended, with a gradual transition to regular foods as tolerated. Certain foods may cause increased gas or changes in stool consistency; keeping a food diary can help identify and manage these. Adequate hydration is necessary to maintain proper bowel function.

Will I need additional treatments after APR?

This depends on your condition. Cancer patients may require follow-up treatments such as chemotherapy or radiotherapy, while others may only need routine monitoring. Regular follow-ups will determine the best plan.

Partnered Programmes & Insurance Plans

For Singaporeans, Singapore Permanent Residents and Foreigners. Please speak to our friendly clinic staff about using your insurance plans.

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Dr Chong Choon Seng

MBBS (NUS)

MRCS (Edinburgh)

Masters in Medicine (Surgery)(NUS)

FRCS (Edinburgh)

Dr Chong is the former Program Director of General Surgery Residency at NUHS, and has more than 10 years of experience as a colorectal and general surgeon.

As an esteemed professional in minimally invasive surgery, Dr. Chong remains committed to achieving optimal outcomes for all surgical conditions, from piles to cancer treatment.

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