ABSTRACT
Abdominoperineal excision of the rectum and anus (APER) was popularized by Ernest Miles at the beginning of the last century. This procedure, that of combining the abdominal and perineal phases of the operation, was a natural extension of the staged procedure of a loop colostomy followed, several weeks later, by a perineal proctectomy performed with the patient in the left lateral position. Despite the inability to extend the excision much above the sacral promontory, this latter operation was the generally accepted procedure for rectal carcinoma, particularly in the pretransfusion era. Miles’ operation of combined abdominoperineal excision of the rectum and anus was developed in order to take account of the lymphatic spread of cancer in a cephalad direction and to obtain a wider clearance of the lymphovascular structures together with the tissues immediately adjacent to the tumor. A greater understanding of the mode of spread of rectal cancer, advances in stapling techniques, and the desire to avoid a permanent stoma has led to the procedure being performed less often; yet population-based audits1, 2 have indicated its continued use in approximately 25 percent of patients with rectal cancer. There has been a resurgence of interest in APER in recent years following the publication of several studies which demonstrated that inadequate ‘clear surgical margins’ were associated with poor local cancer control. Recent technical advances in the performance of APER include sequential rather than combined abdominal and perineal phases to the operation, the use of the prone position for the perineal phase and adaptation of the planes of dissection to obtain a more cylindrical specimen with a wider circumferential clearance in the vicinity of the primary tumor.
