ABSTRACT
In 1874, Theodor Kocher (1841–1917) was the first to recommend excision of the coccyx to facilitate a posterior approach to the mid-rectum for excision of lesions located below the peritoneal reflection. According to Paul Kraske (1851–1930), removal of the coccyx alone did not provide sufficient exposure to the upper part of the mid-rectum. At the 14th meeting of the German Association of Surgeons in 1885, he reported that better exposure could be obtained by dividing the lower margin of the gluteus maximus muscle and the sacrospinous as well as the sacrotuberous ligaments. In addition, he also removed the lowermost part of the left wing of the sacrum. This posterior approach rapidly became a popular surgical option in the treatment of cancer, located in the middle and lower third of the rectum. Unfortunately, Kraske’s operation was complicated by a 90 percent local recurrence rate and a 70 percent incidence of rectocutaneous fistula formation. Because of this high complication rate and the adequate local control of rectal cancer, the procedure never gained wide acceptance outside Europe. The abdominoperineal resection, introduced by Ernest Miles in 1908 and the low anterior resection, described by Claude Dixon in 1939 gradually gained popularity over Kraske’s operation. However, over many decades, a modified posterior approach, without resection of the lowermost part of the left wing of the sacrum, has been used for the local excision of benign rectal neoplasm, such as villous adenoma. This modified Kraske’s operation remained popular until the introduction of transanal endoscopic microsurgery in 1983. This challenging technique enables the excision of large lesions, even in the upper third of the rectum (see Chapter 6.14). Local excision of these lesions by a posterior approach is rarely now indicated. At present, there are two principal remaining indications for the modified Kraske’s approach: the management of presacral tumors and the rectal sleeve procedure.
