Proctectomy
The use of improved surgical techniques, neoadjuvant therapy, and more precise imaging modalities has transformed rectal cancer treatment, improved oncologic outcomes, reduced morbidity and mortality, and enhanced patients’ quality of life. In the current
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Key Concepts • A proper proctectomy with sharp dissection along the visceral and parietal layers of the endopelvic fascia facilitates margin-negative resection, reduces local recurrence, and limits nerve injury associated with sexual dysfunction. • Precise understanding of pelvic anatomy including fascial planes, autonomic nerves, and pelvic floor musculature is critical in performing a proper proctectomy. • The quality of mesorectal excision and the distance of the circumferential radial margin are associated with local pelvic control. • Proctectomy can be performed using open, laparoscopic, and robot-assisted techniques.
Background and History At the beginning of the twentieth century, the majority of patients diagnosed with rectal cancer in Europe and the United States underwent perineal proctectomy—the preferred operation of the day. While this operation was an improvement over previous surgeries, it was highly morbid, with poor oncologic results. In 1908, William Ernest Miles of St. Mark’s Hospital in London recognized that nearly all of his patients suffering from rectal cancer died of recurrent disease within 3 years after perineal proctectomy. On autopsy, he noted that most recurrences were identified in the part of the mesorectum that had been left in place and/or within lymph nodes situated near the left common iliac artery. Miles termed these areas the “zone of upward spread.” He concluded that perineal proctectomy was inadequate because it failed to address the ultimate cause of local recurrence: incomplete excision of the mesorectum, including its lymphovascular supply. Based on his observations, Miles devised a different procedure, which he described as abdominal perineal excision
(APE) or, as it came to be called, abdominoperineal resection (APR). APR soon became the surgical procedure of choice for treatment of carcinoma of the rectum [1]. As Miles described it, APR actually comprised two procedures performed during the same operation: an abdominal operation and a perineal operation. The abdominal part of the APR includes dissection of the rectum and mesorectum and creation of a colostomy; the perineal part includes detachment of the rectum, anus, and levator muscles from the genital/ urinary organs and the ischiorectal fat. Describing the perineal approach in 1910, Miles stressed that the levator muscles should be “divided as far outwards as their origin from the white line so as to include the lateral zone of spread” [2]. Compared with perineal proctectomy, long-term outcomes following this new operation improved considerably. Miles’ emphasis on the necessity of removing the mesorectum in its entirety would become the guiding principle of what is now known as total mesorectal excision (TME). Today, TME remains the gold standard in rectal cancer surgery. TME entails sharp—rather than blunt—dissection of the visceral and parietal layers of the endopelvic fascia, resulting in intact removal of the rectum and mesorectum [3]. In Miles’ time, however, most surgeons continued to perform traditional blu
