Abdominoperineal resection (APR) has remained the gold standard for management of distal rectal adenocarcinoma since the original description by W. Ernest Miles in 1908.1 The classic Miles procedure involved a 1-team approach: after the initial abdominal mobilization of the rectosigmoid colon, the patient was placed in the left lateral position for the perineal proctectomy. Lloyd-Davies2 described the currently popular synchronous, combined approach in 1939 after Devine3 introduced adjustable stirrups to place the patient in the lithotomy position. Several modifications of the Lloyd-Davies APR procedure have been described through the years, but the basic principles espoused by Miles remain unchanged.4
Coronal cross-section of the pelvis. The various fascial linings in relation to the levator ani and the obturator internus muscles are seen. The common anatomical landmarks in the anorectal region are also demonstrated. The broad arrow in the center of the figure indicates the plane of dissection during the perineal dissection and the structures that are encountered.
Sagittal anatomy of the pelvis demonstrating that after the anococcygeal raphe is incised, the strong Waldeyer fascia needs to be divided to gain access to the presacral space.
Inferior view (surgeon's actual view during perineal dissection). A, The superficial external sphincter has been divided to reveal the intimate relation of the deep external sphincter, with the puborectalis seen during deeper dissection into the pelvis. B, More superficially, the 3 components of the external sphincter and the ischiococcygeus/pubococcygeus part of the levator ani are demonstrated.
The almost vertically running fibers of puborectalis are severed from the side by working from above and downward (arrow). The close relationship of the puborectalis to the prostate is shown. Inset, the rectum is sharply angulated by the U-shaped puborectalis sling. The arrow indicates the direction of division of the puborectalis.
A, Key surface landmarks. Shown are the perineal body (PB), right and left ischial tuberosity (IT), and the coccyx (C) with the elliptical incision. B, A crescent-shaped incision is made to divide the anococcygeal raphe.
A, Posteriorly, the tough Waldeyer fascia has to be sharply incised to enter the correct plane of dissection. B, Two fingers are passed beneath the levator to hook the iliococcygeus muscle, which is then divided.
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