Extralevator Abdominoperineal Excision for Rectal Cancer: “Extended” is the Only Correct Route

Gianluca Pellino

Gianluca Pellino, Division of General Surgery, Second University of Naples, Naples, Italy

Correspondence to: Gianluca Pellino, MD, Division of General Surgery, Second University of Naples, Naples, Italy.
Email: gipe1984@gmail.com
Received: August 9, 2013
Revised: October 1, 2013
Accepted: October 8, 2013
Published online: January 21, 2014


Abdominoperineal excision (APE) of the rectum is being performed since more than one hundred years, following the technical description of the procedure reported on Lancet by Sir Ernest Miles. APE can be perfomed either medially to the levator ani (intersphincteric APE) or removing it by sectioning the muscle at its pelvic attachment (extralevator APE, ELAPE). However, some publications recently introduced the concept that the procedure can be classified “standard” or “extended” (“extralevator”). This concept should be carefully examined to avoid confusion.

Key words: Abdominoperianeal resection; Abdominoperineal excision; APE; APR; Extralevator

© 2014 The Author. Published by ACT Publishing Group Ltd.

Pellino G. Extralevator Abdominoperineal Excision for Rectal Cancer: “Extended” is the Only Correct Route. Journal of Gastroenterology and Hepatology Research 2014; 3(1): 937-938 Available from: URL: http://www.ghrnet.org/index.php/joghr/article/view/584


The abdominoperineal excision (APE) of the rectum – also defined as abdominoperineal resection (APR) – was first described in details by Sir W Ernest Miles in 1908[1]. Since then, it has been widely adopted.

In more recent years, an issue was raised because of the higher rate of local recurrences observed after APE than with sphincter saving total mesorectal excision (TME), which also implied poorer surgical results in terms of reoperative pelvic surgery[2]. Several researchers pointed out, hence, that this was due to APE being performed with a so called “standard approach”, meaning that during the abdominal time of APE the levator ani is not sectioned at its attachment to the pelvis, following the muscle until the rectal wall is reached and dividing these structures. Then the excision is continued to the perineum. Consequently, the need for an “extended” route was reported, consisting in the section of the levator ani as proximal as possible to the pelvic wall, allowing to excide a cylindrical specimen (Figure 1). This 'innovative' procedure [extralevator APE (ELAPE)] was reported to achieve much better results in terms of radicality and recurrence-free survival[2,3].

The latter procedure is the one to be performed when carrying out an ELAPE for rectal malignancies. Apart from radicality achieved by a wider excision (with higher rate of free circumferential resection margins), it dramatically reduces the risk of perforation with cancer cells spillage in the body, by avoiding the separation of levator ani from the rectum. In fact, this part of APE is the one which raises the risk of perforation, altogether with anterior dissection during the perineal time of the procedure. In the light of these observations, it seems evident that ELAPE sectioning medially the levator ani should be defined as “incorrect” APE rather than “standard”.

Furthermore, going back to Sir Miles elegant description of APE, it reads “[…] lateral dissection [of the rectum] is carried down to the upper surface of the levatones ani […]”, the patient is turned in semi-prone position for the perineal time; “ […] [levatores ani] muscles should be divided as far outwards as their origin from the “white line” so as to include the lateral zone of spread [..]”[1]. This further highlights that there is no “choice”: the correct ELAPE must include proximal division of levator ani. Other procedures different from ELAPE or intersphincteric APE are wrong.

Dealing with the large perineal defect which a correct ELAPE may determine could be difficult. However, this must not be regarded as a reason not to perform a cylindrical excision. Surgeons who want to perform ELAPE must learn how to reconstruct the perineal wound or must seek for the collaboration of plastic/reconstructive surgeons, as many choices are available to fill larger defects[3].

In conclusion, in order to perform a correct ELAPE for rectal malignancies, there is no other choice than dividing the levator ani at the pelvic wall attachment, exciding it en bloc with the diseased bowel. According to cancer characteristics, APE can be performed going medially to the levator ani without sectioning it (intersphincteric APE); when ELAPE is needed, it must be performed by sectioning the levator ani at its insertion. No midway options are given. Deliberately performing a “standard” APE, as some papers recently defined it (wrong or incorrect APE would be more appropriate), exposes the patients to avoidable risks thus raising ethical concerns.


There are no conflicts of interest with regard to the present study.


1 Miles WE. A method of performing abdomino-perineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon. Lancet 1908; II: 1812-1813

2 Selzner S, Koehler C, Stelzer J, Sims A, Witzigmann H. Extended abdominoperineal excision vs. standard abdominoperineal excision in rectal cancer—a systematic overview. Int J Colorectal Dis 2011;26:1227–1240

3 Holm T, Ljung A, Haggmark T, Jurell G, Lagergren J. Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg 2007; 94:232–238

Peer reviewer: Yoshifumi Nakayama, MD, PhD, Department of Surgery 1, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahata-nishi-ku, Kitakyushu 807-8555, Japan.


  • There are currently no refbacks.

Creative Commons License
This work is licensed under a Creative Commons Attribution 3.0 License.