Background Information:

What are the other Names for the Procedure?

• Abdominoperineal Excision
• AP Resection of Rectum
• APR - Abdominoperineal Resection of Rectum and End Colostomy

What is the Abdominoperineal Resection surgical procedure?

Abdominoperineal Resection involves the surgical removal of the:

• Anus
• Rectum (end portion of the large intestine located just before the anus)
• Sigmoid colon (a portion of the large intestine, immediately next to the rectum)

During the procedure the remaining portion of the sigmoid colon is permanently redirected to the abdominal surface, as an opening to expel feces from the body. This is known as colostomy. 

What part of the Body does the Procedure involve?

An Abdominoperineal Resection involves the anus, rectum, sigmoid colon, abdomen and the perineum (a term used to describe parts of the body involving the anus, genitals, and neighboring organs, muscles, and tissue). 

Why is the Abdominoperineal Resection surgical procedure Performed?

An Abdominoperineal Resection is performed to treat cancer of the rectum and anus. 

What are some Alternative Choices for the Procedure?

Radiation therapy and chemotherapy are usually used as alternatives for rectal and anal cancers. However, in some cases these may not prove to be as effective as a surgery.

What are the Recent Advances in the Procedure?

The recent advances to the procedure are in the use of laparoscopic techniques.

What is the Cost of performing the Abdominoperineal Resection surgical procedure?

The cost of Abdominoperineal Resection procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused by the information regarding Abdominoperineal Resection and on what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist and also recommend another physician, if required
• They can also choose to approach another physician independently. Besides, if the procedure has many alternatives or multiple surgeries, the patient may take a second opinion to understand and choose the best one

What are some Helpful Resources?

http://www.health.qld.gov.au/consent/documents/colorectal_01.pdf

http://www.mdguidelines.com/abdominoperineal-resection-of-rectum

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2789508/ 

Prior to Abdominoperineal Resection surgical procedure:

How is the Abdominoperineal Resection surgical procedure Performed?

• In an Abdominoperineal Resection surgery, an incision is made on the abdomen and the perineum
• The muscles, tissues, and abdominal organs are placed aside, to locate and isolate the sigmoid colon
• The sigmoid colon is then divided well above the area of cancer and the remaining portion of the sigmoid colon is surgically removed along with the rectum, the anus and lymph nodes, after separating them from the neighboring connective tissues
• Drains may be placed during the surgery and are subsequently removed during the post-operative period, if the output is less
• The healthy portion of the sigmoid colon is checked for any signs of cancer or other disease and then brought to the skin surface for a colostomy
• The abdomen and perineum are then closed with sutures, after repositioning the organs, muscles, and tissues

Where is the Procedure Performed?

An Abdominoperineal Resection is performed in a hospital. The patient is admitted, undergoes the procedure and is discharged as per the instruction of the physician.

Who Performs the Procedure?

The surgery is performed either by a trained general surgeon, a gastro-intestinal surgeon, or a colon and rectal surgeon.

How long will the Procedure take?

The surgery may take anywhere between 2-6 hours.

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the surgical procedure and helps avoid unnecessary complications.

• Provide a complete list of medications you are currently, taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
• If you are allergic to any specific medication or food items
• If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
• If you or your family members, have a history of bleeding disorders, or if there is a tendency to bleed more than normal
• If you have diabetes, high blood pressure, chest pains, or have previously suffered from a heart attack
• If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
• If you have a history of frequent bone fractures (this may affect bone-healing, if bones are involved as part of your procedure)

A list of all previous surgical procedures you have undergone, like for example: Removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.

What Preparations are needed, prior to the Procedure?

The preparations needed prior to an Abdominoperineal Resection, include the following:

• The large intestine is prepared before the surgery to avoid any risks of infection. In order to achieve this, the patient is asked to consume a high fiber diet for 3-4 days prior to the surgery. The patient is then put on a regimen of a liquid diet and a laxative is given to completely empty the bowel. This may cause diarrhea and cramps. The patient is then put on a 6-8 hour fast until surgery is performed
• The physician may evaluate the individual’s medical history to gain a comprehensive knowledge of the overall health status of the patient including information related to the medications that are currently being taken
• Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time, before the procedure is performed
• Blood tests may be performed to determine if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
• Avoid application of any topical medicines on the area, prior to the procedure
• It is advisable to quit smoking and the use of any nicotine based products, for a while, before the surgery
• Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
• The patient must avoid eating or drinking at least 8 hours prior to the surgical procedure, depending on when the procedure is arranged
• For persons suffering from diabetes, it is important that the blood sugar stays within the normal range; if not their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines

A physician will request your consent for Abdominoperineal Resection procedure using an Informed Consent Form.

What is the Consent Process before the Procedure?

A physician will request your consent for Abdominoperineal Resection procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is your approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

You must sign the forms only after you are totally satisfied by the answers to your questions. In case of minors and individuals unable to personally give their consent, the individual’s legal guardian or next of kin, shall give their consent for the procedure.

What Tests are needed, before the Abdominoperineal Resection surgical procedure?

Before an Abdominoperineal Resection, the patient has to undergo certain tests such as:

• Routine blood and urine analysis
• Colonoscopy
• Sigmoidoscopy
• Barium Enema
• Ultrasound
• CT Scan

The physician may suggest further tests depending on the health of the patient and their medical history.

What are some Questions for your Physician?

Some of the basic questions that you might ask your physician are as follows:

• What is an Abdominoperineal Resection surgical procedure?
• Why is this procedure necessary? How will this procedure help?
• What does the procedure involve?
• Will the surgery ensure that the cancer will not recur?
• What are the alternatives to this procedure?
• How soon should I get it done? Is there an emergency?
• To what extent will the surgery affect my bowel movement?
• Will the colostomy be permanent? Will it cause problems in the future?
• What are the complications associated with a colostomy?
• What would happen if the surgery is not a success?
• What are the risks while performing the procedure?
• What are the complications that might take place, during recovery?
• How long will it take to recover? When can I resume normal work?
• How many such procedures have you (the physician) performed?
• Are there any lifestyle restrictions or modifications required, after the procedure is performed?
• Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
• Is there any medication that needs to be taken for life, after the procedure?
• What are the costs involved?
• Who are the medical personnel involved in this procedure?

During the Abdominoperineal Resection surgical procedure:

What kind of Anesthesia is given, during the Procedure?

General anesthesia is administered during the procedure.

How much Blood will you lose, during the Procedure?

• Abdominoperineal resection is a complex surgical procedure involving the lower abdomen and excretory organs; the amount of blood loss is difficult to be quantified
• If complications arise during the surgery, then it could lead a further loss of blood

What are the possible Risks and Complications during Abdominoperineal Resection surgical procedure?

The possible risks or complications that may arise during the surgery are:

• Excessive bleeding
• Infection
• Problems that may arise from a colostomy
• Cardiopulmonary complications
• Accidental damage to the ureter
• Blood clot formation in the legs

What Post-Operative Care is needed at the Healthcare Facility after Abdominoperineal Resection surgical procedure?

The healthcare facility must have an intensive care unit (ICU) attached, for immediate post-operative care and recovery. Apart from this no particular care is needed unless complications arise.

After the Abdominoperineal Resection surgical procedure:

What are the possible Risks and Complications after Abdominoperineal Resection surgical procedure?

Post Abdominoperineal Resection surgery, the following complications may arise:

• Infection of the surgical wound
• Bowel leakage inside the abdomen
• Urinary tract infection
• Loss of blood supply to the stoma, after colostomy
• Loss of voluntary control over the bladder
• Bowel blockage
• Hernia around colostomy
• Impotence in men
• Adhesions, leading to intestinal obstruction

What is the Prognosis after the Surgery?

The 5-year survival rate for patients who have undergone the procedure varies, and is based on the cancer stage when treatment occurs. During early stages of cancer, the survival rate is found to be 85-90%; whereas after metastases (last stage), the survival rate could be significantly low.

When do you need to call your Physician?

Do contact your surgeon/physician if you notice any of the following symptoms:

• Pain around the surgical wound
• Pain in the abdomen
• Swelling and redness
• Bleeding or drainage
• Constipation
• Fever
• Dizziness
• Signs of infection
• Any discomfort

What Post-Operative Care is needed at Home after Abdominoperineal Resection surgical procedure?

The patient is advised the following post-operative care at home:

• Keep the wound clean and dry
• Avoid eating foods that may cause an irritation to your stomach
• Have a liquid diet until your physician advises otherwise
• Avoid strenuous exercise
• Complete the course of medication, as prescribed by your surgeon/physician
• Be aware of and completely understand the kind of care, which needs to be taken post-colostomy

How long does it normally take to fully recover, from the Procedure?

It takes about 3 months to completely recover from the surgical procedure.

Additional Information:

What happens to tissue (if any), taken out during the Procedure?

The tissue is taken for further examination and later disposed, as per the standard medical procedure.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

• The tissue removed is processed in the laboratory under a pathologist's supervision
• Slide(s) are prepared once the tissue is processed and this is examined by a pathologist and a pathology report issued
• Depending on the complexity of the case, issue of the report may take anywhere between 72 hours to a week's time

Who will you receive a Bill from, after the Abdominoperineal Resection surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers. 

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• The hospital
• A general surgeon, or a gastro-intestinal surgeon, or a colon and rectal surgeon
• An anesthesiologist (if anesthesia was administered)
• A pathologist (if the tissue was sent for analysis)

The patient is advised to inquire and confirm the type of billing, before an Abdominoperineal Resection is performed.

Thanks and Gratitude:

We sincerely acknowledge and thank Dr. Douglas J. Jones for reviewing the article. His valuable input and feedback has helped enrich the contents of this article.

Douglas J. Jones, MD FACS
Board Certified General Surgeon and Faculty Member
University of Illinois, College of Medicine at Urbana-Champaign
506 S. Mathews Ave., Urbana, IL 61801, USA